Final Questions

What does the final "R" represent when using the I-SBAR-R communication technique? a. Recovery b. Repeat back c. Reorganization d. Reintegration

ANS: B Feedback A Recovery does not represent the final "R" in I-SBAR-R. B The final "R" in I-SBAR-R represents "repeat back," which includes repeating back orders that have been given or clarifying any questions. C Reorganization does not represent the final "R" in I-SBAR-R. D Reintegration does not represent the final "R" in I-SBAR-R.

Which of the following is true in regard to dehydration and the older adult? a. Thirst response is decreased. b. Greater water intake is normal. c. Vomiting and diarrhea do not contribute to dehydration. d. More free water is available in the body because of decreased muscle mass.

ANS: A Feedback A Dehydration is common in the older adult because the thirst response is reduced. B Dehydration results in lower, rather than greater, water intake. C Vomiting and diarrhea can accompany the onset of acute illness, leaving older adults at risk for further dehydration. D With a decrease in muscle mass, there is less, rather than more, free water available in the body.

What are the three major health issues presently afflicting Aboriginal communities in Canada? a. Diabetes, HIV/AIDS, suicide b. Depression, smoking, unprotected sexual practices c. Sexually transmitted infections, environmental pollution, malnutrition d. Sedentary lifestyle, teenage pregnancies, high-calorie diets

ANS: A Feedback A Diabetes is considered to be an epidemic in progress for Canadian Aboriginal peoples. The prevalence of diabetes is three to five times the national average. Human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) cases among Aboriginal peoples have increased steadily over the past decade, whereas the annual number of AIDS cases has levelled off in the rest of the population. The suicide rates in Inuit and First Nations communities are five to six times greater than the rates found in non-Aboriginal communities. B Depression, smoking, and unprotected sexual practices are issues that may be present in Aboriginal communities but are not identified as the most prevalent health issues. C Sexually transmitted infections, environmental pollution, and malnutrition are issues that may be present in Aboriginal communities but are not identified as the most prevalent health issues. D Sedentary lifestyle, teenage pregnancies, and high calorie diets are issues that may be present in Aboriginal communities but are not identified as the most prevalent health issues.

Which of the following liquid forms has an alcoholic ingredient? a. Extract b. Troche c. Tincture d. Aqueous suspension

ANS: C Feedback A Extract does not contain alcohol. B Troche is a lozenge that dissolves in the mouth and does not contain alcohol. C Tincture is a medicinal alcoholic extract from a plant or vegetable. D Aqueous suspension does not contain alcohol.

For the most part, evaluative measures are equivalent to which of the following? a. Planning b. Outcome indicators c. Assessment skills and techniques d. Enactment of the entire nursing process

ANS: C Feedback A Planning and evaluative measures are not equivalent. B Outcome indicators are part of nursing-sensitive client outcomes. C Evaluative measures are equivalent to assessment measures, but they are performed when the nurse makes decisions about the client's status and progress. D Enactment of the entire nursing process is not equivalent to evaluative measures.

It is late at night on the medical unit in the hospital, and the physician calls to leave orders for one of his patients. The licensed practical nurse answers the phone and appropriately responds with which of the following statements? a. "Let me get the registered nurse on the phone." b. "I am unable to take the order at this time. Please call in the morning." c. "Please repeat the order for me, so that I can make sure it is written correctly." d. "Let me have your phone number, and I will have the supervisor call you back."

ANS: A Feedback A A telephone order involves a physician stating a prescribed therapy over the phone to a registered nurse. B "I am unable to take the order at this time. Please call in the morning" is not an appropriate response and is not in the patient's best interest. C It is best to repeat any prescribed orders back to the physician, who can then verify whether it is correct or clarify the order. A registered nurse must be the one to take the verbal order. D "Let me have your phone number, and I will have the supervisor call you back" is not the appropriate response. A registered nurse must take the verbal order; the nursing supervisor does not need to take it.

A 70-year-old patient must have her blood pressure checked during each shift. She asks the nurse to explain her hypertension. The nurse's reply is based on the knowledge that the older adult patient often experiences hypertension because of which of the following changes? a. Vascular changes related to aging. b. Reduction in physical activity c. Ingestion of processed foods high in sodium d. Myocardial damage and venous insufficiency

ANS: A Feedback A Although hypertension is not a normal physiological change of aging, older adults often experience hypertension because of vascular changes. Vascular changes include thickening of vessel walls, narrowing of vessel lumen, and loss of vessel elasticity. Systolic or diastolic hypertension (systolic pressure >140 mm Hg, diastolic >90 mm Hg) is seen in 50% of older adults. B Hypertension is not caused by a reduction in physical activity. C Older adults with hypertension should be counselled on limiting fat and salt in their diets; however, ingestion of processed foods high in salt is not the reason that older adult patients often experience hypertension. D Myocardial damage and venous insufficiency are not the reasons that older adults commonly experience hypertension.

Which one of the following statements related to cognitive functioning in the older adult patient is true? a. Reversible systemic disorders are often implicated as a cause of delirium. b. Cognitive deterioration is an inevitable outcome of aging. c. Delirium is easily distinguished from irreversible dementia. d. Intoxication from therapeutic drugs is a common cause of senile dementia.

ANS: A Feedback A Delirium is a potentially reversible cognitive impairment that is often due to a physiological cause such as an electrolyte imbalance, cerebral anoxia, hypoglycemia, medications, tumours, cerebrovascular infection, or hemorrhage. B Cognitive deterioration is not an inevitable outcome of aging. C Delirium is not always easily distinguishable from irreversible dementia. Because of the close resemblance between delirium and dementia, the presence of delirium must be ruled out whenever dementia is suspected. D The cause of senile dementia is not known. Medications and drug effects can cause delirium.

What is the primary reason for establishing standing orders? a. To provide appropriate nursing autonomy in settings where client needs can change rapidly b. To facilitate adequate care when direct contact with a primary health care provider is not immediately possible c. To allow the nurse to provide certain routine therapies without first notifying the primary health care provider d. To afford the client interventions that reflect the appropriate standard of care in the absence of a primary health care provider

ANS: A Feedback A Licensed prescribing physicians or health care providers in charge of care at the time of implementation approve and sign standing orders. These orders are common in critical care settings and other specialized practice settings where clients' needs change rapidly and require immediate attention, thus providing for nursing autonomy to assess and implement appropriate care. B "To facilitate adequate care when direct contact with a primary health care provider is not immediately possible" is not an appropriate use of standing orders. C "To allow the nurse to provide certain routine therapies without first notifying the primary health care provider" is not an appropriate use of standing orders. D "To afford the client interventions that reflect the appropriate standard of care in the absence of a primary health care provider" is not an appropriate use of standing orders.

Which of the following describes the branch of medicine that deals with the physiological and psychological aspects of aging? a. Gerontic medicine b. Geriatrics c. Gerontology d. Anthropology

ANS: B Feedback A Gerontic nursing is a seldom-used term that reflects the art and practice of nurturing, caring for, and comforting older patients, rather than merely treating disease. B Geriatrics is the branch of medicine that deals with the physiological and psychological aspects of aging and with the diagnosis and treatment of diseases affecting older adults. C Gerontology is the study of all aspects of aging. D Anthropology is not a term used for the study of aging.

For which of the following purposes does the nurse prepare to administer an intradermal injection for the administration of medication? a. Immunization b. Allergy testing c. Anticoagulant therapy d. Low-dose insulin requirements

ANS: B Feedback A Immunization medications are not administered intradermally. B Intradermal injections are typically given for allergy testing or tuberculin screening. C Anticoagulants are not administered intradermally. They are typically given subcutaneously. D Intradermal injections are not used for low-dose insulin requirements.

Readiness for enhanced coping related to successful cancer treatment is an example of which type of nursing diagnosis? a. A risk nursing diagnosis b. A wellness nursing diagnosis c. A health promotion nursing diagnosis d. An incorrectly worded nursing diagnosis, according to NANDA

ANS: B Feedback A Readiness for enhanced coping related to successful cancer treatment is not an example of a risk nursing diagnosis. B Readiness for enhanced coping related to successful cancer treatment is an example of a wellness nursing diagnosis. C Readiness for enhanced coping related to successful cancer treatment is not an example of a health promotion nursing diagnosis. D Readiness for enhanced coping related to successful cancer treatment is not a correctly worded nursing diagnosis, according to NANDA International.

What is the primary purpose of concept mapping? a. To enable reflection on past experiences b. To synthesize relevant data about a patient c. To demonstrate artistic abilities with drawings d. To act as a visual guideline for assisting students with rational thought

ANS: B Feedback A Reflective journaling enables students to reflect on past experiences. B The primary purpose of concept mapping is to synthesize relevant data about a patient, including assessment data, nursing diagnoses, health needs, nursing interventions, and evaluation measures. C Concept mapping's primary purpose is not to allow students to demonstrate their artistic abilities. D An intellectual standard is a guideline for assisting students with rational thought; it is not visual.

A patient on the medical unit receives regular insulin at 7:00 a.m. The nurse is alert to a possible hypoglycemic reaction by which time? a. 7:30 a.m. b. 9:00 a.m. c. 4:00 p.m. d. 8:00 p.m.

ANS: B Feedback A Regular insulin has an onset in 30 minutes. B Regular insulin reaches its peak in 2 to 3 hours after administration. If the patient received regular insulin at 7:00 a.m., the nurse should be alert for a possible hypoglycemic reaction from 9:00 a.m. to 10:00 a.m. C Intermediate-acting insulin (e.g., NPH insulin), not regular insulin, would peak in 6 to 12 hours. D The patient would not be at risk for a hypoglycemic reaction from regular insulin 13 hours after administration. Long-acting insulin would have an effect this much later after administration.

Which of the following is an example of affective learning? a. Skill acquisition b. Values clarification c. Emotional capability d. Learning control of blood glucose levels

ANS: B Feedback A Skill acquisition is an example of psychomotor learning. B Values clarification is an example of affective learning. C Emotional capability is an area for assessment of the patient's readiness to learn. D Learning control of blood glucose levels is an example of cognitive learning.

The client has a nursing diagnosis of Impaired gas exchange as a result of excess secretions. An outcome for the client is that the airways will be free of secretions. A positive evaluation will focus on which of the following client indicators? a. Ability to perform incentive spirometry b. Lungs clearing bilaterally on auscultation c. Complaint of chest pain d. Respiratory rate

ANS: B Feedback A The client's ability to perform incentive spirometry does not determine whether the client's airways are clear. It is an intervention that may help achieve clear airways. B Auscultating lung sounds is the best way to determine whether airways are clear. A positive evaluation is that they are clear, as expected in the outcome statement. C A complaint of chest pain would be a negative outcome and is not the focus for determining whether airways are free of secretions, as written in the outcome statement. D Respiratory rate may be an indicator of respiratory status, but it is not the best way to determine whether airways are free of secretions.

A parent tells the pediatric nurse practitioner, "I've never told anyone this information about my son." This statement is an example of what? a. Identifying problems and goals b. Building trust c. Clarifying roles d. Revealing

ANS: B Feedback A The parent's statement is not an example of identifying problems and goals. B The parent's statement is an example of trust. Trusting another person involves risk and vulnerability, but it also fosters open, therapeutic communication and enhances the expression of feelings, thoughts, and needs. C The parent's statement is not clarifying roles of the nurse and patient. D The parent's statement is not an example of revealing. Although the parent may have provided information that was never before revealed, in this statement the parent is indicating that there is trust between himself or herself and the nurse practitioner.

During which phase of the helping relationship does the nurse assess a patient's health status? a. Pre-interaction b. Orientation c. Working d. Termination

ANS: B Feedback A The pre-interaction phase does not include the nurse's assessment of a patient's health status. B During the orientation phase, the nurse assesses a patient's health status. C The working phase does not include the nurse's assessment of a patient's health status. D The termination phase does not include the nurse's assessment of a patient's health status.

The patient has a prescription for a medication that is administered via an inhaler. Which of the following will allow the nurse to determine whether the patient requires a spacer for the inhaler? a. The dosage of medication required b. The coordination of the patient c. The schedule of administration d. The use of a dry powder inhaler

ANS: B Feedback A The use of a spacer is not dependent on the dosage of medication. B Spacers are especially helpful when the patient has difficulty coordinating the steps involved in self-administering inhaled medications. C The use of a spacer is not dependent on the schedule of administration. D Spacers are not required with the use of a dry powder inhaler.

The nurse is evaluating the integrity of the ventrogluteal injection site. How does the nurse find the site? a. By locating the middle third of the lateral thigh b. By locating the greater trochanter, anterior iliac spine, and iliac crest c. By locating the anterior aspect of the upper thigh d. By locating the acromion process

ANS: B Feedback A The vastus lateralis site is found by locating the middle third of the lateral thigh. B The nurse finds the ventrogluteal site by locating the greater trochanter with the heel of the hand, the anterior iliac spine with the index finger, and the iliac crest with the middle finger. C The anterior aspect of the thigh may be used for subcutaneous injections; locating it is not how the ventrogluteal site is located. D The acromion process is used to locate the deltoid site.

Which of the following statements by the nurse includes the elements identified for use during self-introduction? a. "I'm Sally. I will be taking care of you for today." b. "Hello, Mr. MacInnis. I'm your nurse today." c. "Good morning, Mr. MacInnis. I am a student nurse; my name is Sally." d. "Hi, dear. My name is Sally. I will be your registered nurse for the next 2 days."

ANS: C Feedback A "I'm Sally. I will be taking care of you for today" does not acknowledge the patient and does not include the nurse's designation. B "Hello, Mr. MacInnis. I'm your nurse today" does not state the nurse's name or clarify her designation; nurse can mean several different designations. C A proper self-introduction includes acknowledging the patient, giving your name, and indicating your status. "Good morning, Mr. MacInnis. I am a student nurse; my name is Sally" acknowledges the patient and states the nurse's name as well as her nursing designation. D While "Hi, dear. My name is Sally. I will be your registered nurse for the next 2 days" contains the components of stating the nurse's name and designation, using terms such as dear, honey, or sweetheart when acknowledging the patient is inappropriate, and may be perceived as disrespectful and unprofessional.

Which of the following activities helps students to "see the other"? a. Concept map b. Nursing process c. Journal writing d. Resource allocation decisions

ANS: C Feedback A A concept map is a visual representation of patient problems and interventions and is not an activity that directly helps students to "see the other." B The nursing process is not an activity that directly helps students to "see the other." C Reflective journal writing can help students learn to "see the other" when working with patients and families, even though the student has not had a similar experience. D Resource allocation decisions do not help students to "see the other."

How should the nurse promote the comfort of the terminally ill patient who is experiencing constipation? a. Offer a low-residue diet. b. Reduce fluid intake. c. Administer stool softeners. d. Protect skin from breakdown.

ANS: C Feedback A A high-residue diet would be implemented instead of a low-residue diet. B Fluid intake would be increased with constipation, not restricted. C Stool softeners are administered to the terminally ill patient who is experiencing constipation. D Skin needs protection from breakdown when the patient is experiencing diarrhea, not constipation.

Nursing diagnoses meet specific criteria so they accurately reflect both the client's problem and the possible etiology involved. Which one of the following statements is an example of an appropriately written nursing diagnosis? a. Acute pain related to left mastectomy b. Impaired gas exchange related to altered blood gases c. Anxiety related to uncertainty over surgery d. Need for high-protein diet related to alteration in nutrition

ANS: C Feedback A A medical diagnosis should not be recorded as an etiology because nursing interventions cannot change the medical diagnosis. It would be appropriate to state: Acute pain related to impaired skin integrity secondary to mastectomy incision. B The nursing diagnosis, Impaired gas exchange related to altered blood gases, is written incorrectly because it uses supportive data of the problem as an etiology. C The nursing diagnosis, Anxiety related to uncertainty over surgery, is written correctly. It defines a problem and its possible cause; in this case, the problem is anxiety, and its possible cause is uncertainty over surgery. The nurse can provide detailed instructions on the surgical procedure, recovery process, and postoperative care activities. D The nursing diagnosis, Need for high-protein diet related to alteration in nutrition, does not identify the problem and etiology. It identifies the client's goal rather than the problem. It could be reworded as: Imbalanced nutrition: less than body requirements related to inadequate protein intake.

The client recently became febrile and stated he felt "hot." The nurse takes the client's temperature and finds it to be 38.2°C. In addition, the client's pulse rate is 88 beats per minute, and his blood pressure (BP) is 168/80 mm Hg. Which of the following is an example of subjective data? a. Pulse rate of 88 beats per minute b. BP of 168/80 mm Hg c. The statement regarding his feeling hot d. Body temperature of 38.2°C

ANS: C Feedback A A pulse rate of 88 beats per minute is an example of objective data. Objective data are observations or measurements made by the data collector. B A BP of 168/80 mm Hg is something that can be measured and therefore is an example of objective data. C Subjective data are the client's perceptions about his or her health problems. The statement by the client regarding his feeling hot is an example of subjective data. D Becoming febrile can be determined by measurement and therefore is an example of objective data.

The nurse recognizes that changes in demographics have an influence on health care delivery. According to the 2006 Canadian Census, what is the ratio of the total population that was born outside of Canada? a. One in three b. One in four c. One in five d. One in ten

ANS: C Feedback A According to the 2006 Census, the number of visible minorities that accounted for Canada's total population that year was one in three. B According to the 2006 Census, one in four of the population's visible minorities in that year were Black. C According to the 2006 Census, approximately 19.8% (one in five) of Canada's total population that year was born outside of the country, the highest level in 75 years. D According to Statistics Canada, Chinese accounted for one in ten of the visible minority population in 2006.

The nurse is documenting administration of a medication that is given at 10:00 a.m., 2:00 p.m., and 6:00 p.m. Which of the following medications is the nurse documenting? a. Morphine sulphate, 10 mg q4h prn b. Propranolol (Inderal), 10 mg orally BID c. Diazepam, 5 mg orally TID d. Cephalexin (Keflex), 500 mg orally q8h

ANS: C Feedback A Although the medication is being given at 4-hour intervals, it is not being given every 4 hours. If it were given every 4 hours, it could be given six times in 24 hours, not three, as with TID administration. B "Twice a day" is the meaning of "BID." The patient is receiving the medication three times a day. C The medication is being given three times a day at 4-hour intervals. The medication the nurse is documenting is diazepam, 5 mg orally TID. D The medication administration is not spaced apart as every 8 hours.

An identified outcome for the family of the patient with a terminal illness is that they will be able to provide psychological support to the dying patient. To assist the family to meet this outcome, which of the following should the nurse plan to include in the teaching plan? a. Demonstration of bathing techniques b. Application of oxygen devices c. Recognition of patient needs and fears d. Information on when to contact the hospice nurse

ANS: C Feedback A Demonstration of bathing techniques may help the family meet the dying patient's physical needs but would not provide psychological support. B Application of oxygen devices may help the family meet physical needs for the patient but would not provide psychological support for the patient. C A dying patient's family is better prepared to provide psychological support if the nurse discusses with them ways to support the dying person and listen to needs and fears. D Information on when to contact the hospice nurse is important knowledge for the family to have and may help them feel they are being supported in caring for the dying patient. However, contact information does not help the family provide psychological support to the dying patient.

Which of the following actions must the nurse take in preparing two different medications from two vials? a. Inject fluid from one vial into the other. b. Uncap the syringe, and wipe the needle with an alcohol preparation before inserting into either vial. c. Discard the medication from vial number two if medication from vial number one is pushed into it. d. Insert air into the first vial, but not the second vial.

ANS: C Feedback A Fluid from one vial should not be injected into another, as it would contaminate the second vial. B The needle should not be wiped with alcohol. It is considered sterile and does not need to be wiped with alcohol. Wiping the needle would place the nurse at risk for a needle stick. C If a vial becomes contaminated with another medication, it should be discarded. D Air should be inserted into both vials, making sure the needle does not touch the solution in the first vial.

In which year was the Canadian Multiculturalism Act passed? a. 1969 b. 1982 c. 1988 d. 1992

ANS: C Feedback A In 1969, the Official Languages Act was passed (and was updated in 1988). B In 1982, the Canadian Constitution Act was passed. C The Canadian Multiculturalism Act was passed in 1988, in recognition of Canada's cultural diversity. This Act enshrines the enhancement and preservation of multiculturalism in Canada. D Nothing of note happened in 1992 related to the Canadian Multiculturalism Act.

The nurse is working with a patient who has recently had a colostomy. The patient is having difficulty using the supplies that are provided for the ostomy care. The nurse investigates the other types of available supplies and works with the patient to see which ones work best for him or her. This is an example of which type of critical thinking strategy? a. Inference b. Management c. Problem solving d. Diagnostic reasoning

ANS: C Feedback A Inference is the process of drawing conclusions. B Management is not a critical thinking strategy. C This is an example of the critical thinking strategy of problem solving. The nurse gathers information from the patient and combines that information with what the nurse already knows about ostomy care to find a solution. Effective problem solving involves the examination of alternatives. D Diagnostic reasoning is a process of determining a patient's health status after the nurse assigns meaning to the behaviours, physical signs, and symptoms presented by the patient.

Which of the following is the second step of data analysis? a. Interpret the data. b. Recognize a trend by cues. c. Compare with normal standards. d. Formulate a reasoned choice.

ANS: C Feedback A Interpreting the data is the entire process of data analysis, not just a step. B Recognizing a pattern or trend by cues is the first step of data analysis. C The second step of data analysis is to compare the data with normal standards. D Making a reasoned choice is the third and final step of data analysis.

Which of the following occurs when the nurse objectively evaluates the degree of success in achieving outcomes of care? a. A client interview b. The addition of nursing diagnoses in response to outcomes of care c. A comparison of established outcome criteria and actual behaviour d. A revision of the outcome indicators to align with client health progress

ANS: C Feedback A Interviewing the client is the assessment that would have been completed before evaluating the degree of success. B The addition of nursing diagnoses in response to outcomes of care does not occur during the evaluation of the degree of success in achieving outcomes of care. C Comparing the established outcome criteria with the actual behaviour or response is the third step in objectively evaluating the degree of success in achieving outcomes of care. D Revising the outcome indicators to align with client health progress is not appropriate.

Which age-related change is true in regard to the aging patient and medication use? a. Liver mass increases. b. Brain receptors become less sensitive. c. Enzymes lose the ability to process some drugs. d. Absorption and active transport mechanisms increase.

ANS: C Feedback A Liver mass shrinks in the aging patient. B Brain receptors become more sensitive with aging. C An expected age-related change is that enzymes lose their ability to process some drugs, thus prolonging drug half-life. D Absorption and active transport mechanisms decline with aging.

The nurse recognizes that factors associated with aging influence the musculoskeletal system. Which one of the following statements does the nurse recognize as being correct? a. Older men have a greater problem with osteoporosis. b. Muscle fibres increase in size and become tight. c. Exercise reduces the loss of bone mass. d. Muscle strength does not diminish as much as muscle mass does.

ANS: C Feedback A Postmenopausal women have a greater problem with osteoporosis than do older men. B Muscle fibres are reduced in size with aging. C Older adults who exercise regularly do not lose as much bone and muscle mass or muscle tone as do those who are inactive. D Muscle strength diminishes in proportion to the decline in muscle mass.

When teaching a patient with attention deficit-hyperactivity disorder (ADHD), the nurse must be aware of what? a. Return demonstration of a skill is not appropriate for this patient. b. The nurse must ensure that the patient's environment is stimulating in order to engage his or her focus. c. Sessions must be short, as the patient may have a low threshold of frustration. d. The patient will have no difficulty remaining focused when engaging in health promotion-related teaching topics.

ANS: C Feedback A Return demonstration of a skill is an appropriate learning strategy for a patient with ADHD. B The nurse should ensure that the environment is minimally stimulating, so that there are minimal competing stimuli for the patient's attention. C When teaching a patient with ADHD, it is important that the nurse know that he or she may have a low threshold of frustration; therefore, the nurse should plan for the teaching sessions to be short. D Patients with ADHD have difficulty remaining focused during all educational sessions.

The nurse knows that which of the following medications absorb most quickly? a. Tablets b. Capsules c. Suspensions d. Medications with a base pH

ANS: C Feedback A Suspensions and solutions are absorbed more readily than tablets. B Suspensions and solutions are absorbed more readily than capsules. C Suspensions and solutions are absorbed more readily than tablets, capsules, and medications with a base pH. D Suspensions and solutions are absorbed more readily than medications with a base pH.

The client smokes two packs of cigarettes per day. The nurse works with the client, and they agree that the client will smoke one cigarette less each week, until he is down to one pack per day. In three weeks, the client is smoking two packs of cigarettes per day. This is an example of which of the following? a. A realistic goal b. A compliant client c. An unmet outcome d. A nonmeasurable goal

ANS: C Feedback A The goal may or may not have been realistic, but the nurse is evaluating whether the expected outcome was met, so this is an example of an unmet outcome. B The client is noncompliant. C The scenario is an example of an unmet outcome. During evaluation, the nurse is able to determine that the client has not met the expected outcome of decreasing smoking by one cigarette each week; he is still smoking the same amount. D The goal is measurable. During evaluation, the nurse determines whether expected outcomes are met to judge if certain goals have been met.

Nursing diagnoses meet specific criteria so they accurately reflect both the client's problem and the possible etiology involved. Which one of the following statements is an example of an appropriately written nursing diagnosis? a. Cardiac output decreased related to motor vehicle accident b. Potential for injury related to improper teaching in the use of crutches c. Ineffective airway clearance related to increased secretions d. Risk for change in body image related to cancer

ANS: C Feedback A The nursing diagnosis, Cardiac output decreased related to motor vehicle accident, is written incorrectly. The etiology is not treatable. B The nursing diagnosis, Potential for injury related to improper teaching in the use of crutches, is written incorrectly. It identifies the nurse's problem and not the client's. C The nursing diagnosis, Ineffective airway clearance related to increased secretions, is written appropriately. It identifies a problem by using a North American Nursing Diagnoses Association (NANDA) International diagnostic statement and connects it to its etiology. D The nursing diagnosis, Risk for change in body image related to cancer, is written incorrectly. It uses a medical diagnosis for the etiology.

The nurse is working with a patient on an inpatient hospice unit. Which of the following actions should the nurse take in order to maintain the patient's sense of self-worth during the end of life? a. Leaving the patient alone to deal with final affairs b. Calling on the patient's spiritual advisor to take over care c. Spending time with the patient and allowing him or her to share life experiences d. Having a grief counsellor visit

ANS: C Feedback A The patient should not be left alone to feel abandoned or isolated. B The nurses can help the patient meet spiritual needs by facilitating connections to a spiritual practice or community and supporting the expression of culturally held beliefs. The patient's spiritual advisor also may be called on but is not the only source of spiritual support. The nurse who turns care over to the spiritual advisor is not promoting the patient's sense of self-worth, as it may imply the patient is not worthy of the nurse's time or attention. C Taking time to let the patient share his or her life experiences, particularly what has been meaningful, enables the nurse to know the patient better. Knowing the patient then facilitates choice of therapies that promote patient decision making and autonomy. Planning regular visits also helps the patient maintain a sense of self-worth, because it demonstrates that he or she is worthy of the nurse's time and attention. D A grief counsellor may be requested to visit if the patient is experiencing complicated grief. Having a grief counsellor visit may be less helpful than spending time with the patient, to help maintain a patient's sense of self-worth.

Which of the following frequently occurs in complex critical thinking? a. The active seeking of new knowledge b. Determination of the significance of a problem c. Learning what is actually happening in a situation d. Awareness that conflicting solutions to a problem exist

ANS: D Feedback A Actively seeking new knowledge is evident in basic critical thinking, not complex critical thinking. B Determining the significance of a problem is evident when the student engages in basic critical thinking, not complex critical thinking. C Learning what is actually happening in a situation is a component of data collection, not complex critical thinking. D In complex critical thinking, the nurse's thinking abilities change as awareness is recognized to look beyond expert opinion and realize that alternative, often conflicting solutions to a problem or issue exist.

The nurse is teaching the patient how to prepare 10 units of short-acting (regular) insulin and 5 units of intermediate-acting NPH insulin for injection. Which of the following instructions does the nurse give the patient? a. Inject air into the short-acting (regular) insulin, then into the intermediate-acting NPH insulin. b. Withdraw the short-acting (regular) insulin first. c. Inject air into and withdraw the intermediate-acting NPH immediately. d. Inject air into both vials, and withdraw the short-acting (regular) insulin first.

ANS: D Feedback A Air should be injected into the vial of intermediate-acting NPH insulin and then into the vial of short-acting (regular) insulin. B The short-acting (regular) insulin should be withdrawn after air has been injected into both vials. C Air should be injected into the vial of intermediate-acting NPH insulin and then into the vial of short-acting (regular) insulin. The short-acting (regular) insulin should be withdrawn immediately after injecting the air into the vial of short-acting (regular) insulin. Then the intermediate-acting NPH insulin is withdrawn. D The patient should be taught to inject air into both vials and withdraw the short-acting (regular) insulin first.

A community health screening is being held for residents at the local town hall. The nurse is alert to the biocultural history of patients and aware that which of the following individuals have a greater potential for and incidence of tuberculosis? a. Black Canadians b. Jewish persons c. Southern Asians d. First Nations and Inuit peoples

ANS: D Feedback A Black persons have a predisposition to hypertension. B Tay-Sachs disease is linked to Ashkenazi Jews. C Lactose intolerance is frequently observed among Southern Asians. D According to Health Canada (2011), the prevalence of tuberculosis among First Nations and Inuit peoples is eight to ten times higher than the national average.

The nurse is evaluating the responses of patients to teaching sessions. Which one of the following is an example of an evaluation of a psychomotor skill? a. "Patient is able to state side effects of medication." b. "Patient responds appropriately to eye contact." c. "Patient planned an exercise program." d. "Patient uses the cane correctly."

ANS: D Feedback A Having the patient state side effects of medication is an example of an evaluation of cognitive learning. B Determining whether a patient responds appropriately to eye contact is an example of evaluation of affective learning. C The patient who planned an exercise program is demonstrating cognitive learning. D Determining whether the patient is able to demonstrate a newly learned skill is an example of an evaluation of a psychomotor skill. Psychomotor learning involves acquiring skills that require the integration of mental and muscular activity, such as walking with a cane.

Which one of the following interventions selected by the nurse is classified as Level 2, Domain 2 (Physiological: Complex Care)? a. Maintaining regular bowel elimination b. Promoting the health of the family c. Managing restricted body movement d. Restoring tissue integrity

ANS: D Feedback A Maintaining regular bowel elimination is classified as Level 2, Domain 1 (Physiological: Basic Care). B Promoting the health of the family is classified as Level 2, Domain 5 (Family Care). C Managing restricted body movement is classified as Level 2, Domain 1 (Physiological: Basic Care). D Interventions to maintain or restore tissue integrity are classified as Level 2, Domain 2 (Physiological: Complex Care).

Myths exist regarding the older adult population in Canada. Which of the following is the nurse aware is true about the majority of older adults? a. They are forgetful and confused. b. They live in institutional settings. c. They are unable to care for themselves. d. They continue to enjoy sexual relationships.

ANS: D Feedback A Older adults are described as having a good memory and broad interests. B Most older adults live in noninstitutional settings. C Most older adults are able to care for themselves. D It is true that older adults continue to enjoy sexual relationships.

Which of the following is the most effective way in the acute care environment to determine the patient's identity before administering medications? a. Ask the patient's name. b. Check the name on the chart. c. Ask the other caregivers. d. Check the patient's name band.

ANS: D Feedback A The nurse may ask the patient his or her name if the identification bracelet is missing or illegible, and obtain a new identification bracelet for the patient. The nurse should ask the patient to state his or her full name. The nurse should not merely say the patient's name and assume that the patient's response indicates that he or she is the right person. B Checking the name on the chart does not identify the right patient. C Asking other caregivers is not the most effective way to determine a patient's identity before administering medications. The nurse should develop the habit of checking the patient's name band. D To identify the patient correctly, the nurse checks the medication administration record against the patient's identification bracelet and asks the patient to state his or her name to ensure that the patient's identification bracelet has the correct information.

Which of the following nursing interventions is the best example of the implementation part of the nursing process? a. Determining that the patient's ankle edema is worse after he ambulates b. Asking the patient to rate his ankle pain after receiving oral pain medication c. Arranging for the patient to receive pain medication d. Crushing the patient's pain medication to facilitate easier swallowing and thus minimize choking

ANS: D Feedback A Assessment involves gathering data. B Assessment involves gathering data. C Planning involves establishing goals and expected outcomes. D Taking the appropriate action demonstrates the implementation step in the nursing process.

The nurse administers the IM medication of iron by the Z-track method. Why was this method used? a. To provide faster absorption of the medication b. To reduce discomfort from the needle c. To provide a more even absorption of the drug d. To prevent the drug from irritating sensitive tissue

ANS: D Feedback A The Z-track method does not provide faster absorption of the medication. B The Z-track method does not reduce discomfort from the needle. C The Z-track method does not provide a more even absorption of the drug. D The Z-track method is used to minimize local skin irritation by sealing the medication in muscle tissue.

The nurse is discussing future treatments with a patient who has a terminal illness. The nurse notes that the patient has not been eating and responds to the nurse's information by stating, "What does it matter?" Which of the following is the most appropriate nursing diagnosis for this patient? a. Social isolation b. Hopelessness c. Denial d. Powerlessness

ANS: D Feedback A The patient's behaviour and verbalization is not an example of social isolation. The patient is not avoiding others or being restricted from seeing others. B Hopelessness is more reflective of the comment, "I have no future," than "What does it matter?" C The patient's behaviour and verbalization does not indicate denial. D A defining characteristic for the nursing diagnosis of "powerlessness" may include the patient stating, "What does it matter?" when offered choices or information concerning him or her.

The patient is to receive a medication via the buccal route. Which of the following actions does the nurse plan to implement? a. Place the medication inside the cheek. b. Crush the medication before administration. c. Offer the patient a glass of orange juice after administration. d. Use sterile technique to administer the medication.

ANS: A Feedback A Administration of a medication by the buccal route involves placing the solid medication in the mouth and against the mucous membranes of the cheek until the medication dissolves. B Crushing the medication is not necessary, as it is designed to dissolve in the patient's cheek. C Patients are not to take any liquids with medications given by buccal administration or immediately thereafter. D The mouth is not sterile. Sterile technique is not necessary for buccal administration.

Which of the following is a specific and measurable behavioural response that reflects independence in function? a. Client goal b. Priority setting c. Nursing diagnosis d. Concept mapping

ANS: A Feedback A A client goal is a specific and measurable behavioural response that reflects a client's highest possible level of wellness and independence in function. B Priority setting is not a specific and measurable behavioural response that reflects independence in function. C A nursing diagnosis is not a specific and measurable behavioural response that reflects independence in function. D Concept mapping is not a specific and measurable behavioural response that reflects independence in function.

The patient continues to ask questions about a surgical wound and states, "I think I would like help the first time I look at my wound." This is an example of which of the following? a. Guided response b. Adaptation c. Perception d. Organizing

ANS: A Feedback A A guided response is the performance of an act under the guidance of an instructor. The patient who is seeking help is demonstrating a guided response. B Adaptation occurs when a person is able to change a motor response when unexpected problems arise. This patient is not exhibiting adaptation. C Perception is being aware of objects or qualities through the use of sense organs. This situation is not an example of perception. D Organizing is developing a value system by identifying and organizing values and resolving conflicts. This situation is not an example of organizing.

Active listening and body language work together. Which of the following actions does the nurse take in addition to actively listening to the patient? a. Sits facing the patient b. Keeps arms and legs crossed c. Leans back in the chair away from the patient d. Avoids eye contact as much as possible

ANS: A Feedback A Active listening means being attentive to what the patient is saying both verbally and nonverbally. A nonverbal skill to facilitate attentive listening is to sit facing the patient. Facing the patient gives the message that the nurse is there to listen and is interested in what the patient is saying. B For active listening, the arms and legs should be uncrossed, which suggests that the nurse is "open" to what the patient says. C For active listening, the nurse should lean toward the patient. Leaning back in the chair away from the patient conveys that the nurse is not involved and interested in the interaction. D For active listening, the nurse should establish and maintain intermittent eye contact. Eye contact conveys the nurse's involvement in and willingness to listen to what the patient is saying.

A patient has been recently diagnosed with Alzheimer's disease. When teaching the family about the prognosis, what must the nurse explain? a. The disease usually progresses gradually, with a deterioration of function. b. Many individuals can be cured if the diagnosis is made early. c. Diet and exercise can slow the process considerably. d. Few patients live more than three years after the diagnosis.

ANS: A Feedback A Alzheimer's disease usually progresses gradually, with a deterioration of function. B No cure is known for Alzheimer's disease, but medications can be given to slow the progression of symptoms. C Medications, not diet and exercise, can slow the process of Alzheimer's disease considerably. D Patients may live many years after the diagnosis of Alzheimer's disease.

With regard to metabolism, when does biotransformation occur? a. When enzymes detoxify and degrade the biologically active chemicals b. After a medication is absorbed by the body c. Once the medication binds to proteins after absorption d. When proteins are bound to albumin and considered still active

ANS: A Feedback A Biotransformation occurs when enzymes detoxify, degrade, and remove the biologically active chemicals. B Biotransformation does not occur after a medication is absorbed by the body. C Biotransformation does not occur once the medication binds to proteins after absorption. D Biotransformation does not occur when proteins are bound to albumin and considered still active.

A number of variables may influence the patient's communication with the health care team. Which of the following is an example of an interpersonal variable? a. Postoperative discomfort b. An extremely warm room c. A talkative roommate d. A loud television

ANS: A Feedback A Interpersonal variables are factors within both the sender and receiver that influence communication. Perception is one such variable; each person's view of reality is unique and is formed by his or her expectations or experiences. Examples of interpersonal variables are postoperative discomfort, anxiety, and medication effects. B An extremely warm room is an example of an environmental variable that may affect communication because of the resulting discomfort. C A talkative roommate is an example of an environmental variable that may affect communication because of the distraction and lack of privacy. D Noise, such as a loud television, is an example of an environmental variable that may affect communication.

In planning to teach an older adult patient, the nurse should incorporate which of the following teaching methods or principles into the plan? a. Keeping teaching sessions short b. Teaching in the early morning or late evening c. Putting as much as possible into each teaching session d. Focusing on teaching a family member instead

ANS: A Feedback A Keeping teaching sessions short is an appropriate method when teaching an older adult patient. B The older adult should be taught when the patient is alert and rested, not in the early morning or late evening. C The teaching session should not be filled with numerous topics. D The older adult patient is capable of learning and should be the focus. A family member may be included in teaching, but the older adult patient should not be excluded.

What age signifies the beginning of older adulthood? a. 55 years b. 60 years c. 65 years d. 70 years

ANS: C Feedback A The age of 55 is not used as the lower boundary to define older adulthood. B The age of 60 is not used as the lower boundary to define older adulthood. C The age of 65 continues to be used as the lower boundary to define older adulthood. D The age of 70 is not used as the lower boundary to define older adulthood.

The patient is to receive a Mantoux test for tuberculosis. This test is administered via an intradermal injection. The nurse recognizes that which angle of injection is used for an intradermal injection? a. 15 degrees b. 30 degrees c. 45 degrees d. 90 degrees

ANS: A Feedback A The angle of injection for an intradermal injection is 5 to 15 degrees. B The correct angle for an intradermal injection is not 30 degrees. C Subcutaneous injections may be administered at a 45-degree angle. D Subcutaneous or intramuscular injections may be administered at a 90-degree angle.

In working with a patient who is newly diagnosed with diabetes mellitus, the nurse provides feedback to the patient on her progress in learning the treatment regimen. Which statement by the nurse demonstrates the use of therapeutic communication? a. "I believe that you have come a long way in learning how to manage your care." b. "It didn't look as if you were ever going to be able to get the injection technique right." c. "You really need to be checking your blood sugar more often unless you want to come back here to the hospital." d. "You don't appear to have any interest in your dietary intake."

ANS: A Feedback A The nurse is demonstrating the use of therapeutic communication by sharing hope. The nurse is pointing out that personal growth can come from illness experiences. B "It didn't look as if you were ever going to be able to get the injection technique right" is a negative statement. The nurse should not state observations that might embarrass or anger the patient. C "You really need to be checking your blood sugar more often unless you want to come back here to the hospital" is a response that does not demonstrate the use of therapeutic communication. It implies disapproval and is an aggressive, threatening type of response. D "You don't appear to have any interest in your dietary intake" is not a therapeutic statement; it is negative and aggressive in nature. Even if it is a true observation, it is one the nurse should not state, as it could anger or embarrass the patient.

The nurse is administering a metered-dose inhaler to a patient using a spacer. The nurse instructs the patient to exhale completely and then depresses the medication chamber. How long does the nurse instruct the patient to inhale deeply and slowly through the mouth before holding the breath for 10 seconds? a. 3 to 5 seconds b. 10 to 15 seconds c. 15 to 20 seconds d. 25 to 30 seconds

ANS: A Feedback A The nurse should instruct the patient to inhale deeply and slowly for 3 to 5 seconds. B Inhalation time should not be for 10 to 15 seconds. C Inhalation time should not be for 15 to 20 seconds. D Inhalation time should not be for 25 to 30 seconds.

The nurse is demonstrating to the patient how to put on antiembolism stockings. In the middle of the lesson, the patient asks, "Why have my feet been swelling?" The nurse stops and responds to the patient, adhering to which of the following teaching principles? a. Timing b. Setting priorities c. Building on existing knowledge d. Organizing teaching materials

ANS: A Feedback A The nurse who stops a demonstration of applying antiembolism stockings to answer a patient's question is following the teaching principle of timing. If the patient has a question, it is important to answer the question right away, so the focus can return to the task being taught. B Setting priorities is important to conserve the time and energy of the patient and nurse. The nurse who stops to answer a question is not setting priorities. C A patient learns best on the basis of preexisting cognitive abilities and knowledge. This situation is not an example of building on existing knowledge. D Organizing teaching material means that the nurse considers the order in which to present the information. This is not an example of organizing teaching materials.

Hospice nursing care has a different focus for the dying patient. Which of the following should the nurse know about patient care provided through a hospice? a. It is designed to meet the patient's individual wishes, as much as possible. b. It is usually aimed at offering curative treatment for the patient. c. It is involved in teaching families to provide postmortem care. d. It does not include an interdisciplinary care team.

ANS: A Feedback A The nurse's role in hospice nursing care is to meet the primary wishes of the dying patient and to be open to the individual desires of each patient. The nurse supports a patient's choice in maintaining comfort and dignity. B Hospice care is for the terminally ill. It is not aimed at offering curative treatment but rather emphasizes palliative care. C Hospice care may provide bereavement follow-up for the family after a patient's death, but hospice nurses typically do not teach the family postmortem care. D Hospice care programs include provision of an interdisciplinary care team of physicians, nurses, spiritual advisers, social workers, and counsellors.

The nurse has important information to share with a parent who has brought his child to the emergency department. The nurse discovers that the parent, who appears very anxious, has just learned that his son will require surgery. What is the most effective teaching approach in this situation? a. One-on-one discussion b. Preparatory instruction c. Demonstration instruction d. Group instruction

ANS: A Feedback A The one-on-one discussion allows the nurse the opportunity to present information informally, providing the parent with the opportunity to ask questions and share concerns. This would be the most effective teaching approach in this situation, as it gives the parent the opportunity to express concerns and ask questions. B The preparatory instruction allows the nurse the opportunity to provide information about procedures and helps patients anticipate what will happen. This is not an appropriate intervention initially. C Demonstration instruction helps teach psychomotor skills and is not the most effective teaching approach in this situation. D Group instruction is an economical way to teach information to several patients; however, this would not be an effective teaching approach in this situation.

The nurse is evaluating the responses of patients to teaching sessions. Which of the following is an example of an evaluation of a patient's attainment of a cognitive skill? a. "Patient explains that the medication should be taken with meals." b. "Patient looks at the surgical incision without prompting." c. "Patient uses crutches appropriately to go up and down stairs." d. "Patient dresses self after breakfast."

ANS: A Feedback A The patient who is able to explain that the medication should be taken with meals is demonstrating attainment of a cognitive skill. B The patient who is able to look at the surgical incision without prompting is demonstrating attainment of affective learning. C The patient who uses crutches appropriately is demonstrating attainment of a psychomotor skill. D The patient who dresses himself or herself after breakfast is most likely demonstrating attainment of psychomotor learning.

A patient is admitted for a computed tomography scan of the cranium. As the nurse explains this diagnostic test, the patient moves away from the nurse. This is an example of what influencing factor in communication? a. Space b. Gender c. Environment d. Sociocultural background

ANS: A Feedback A The patient who moves away from the nurse during a conversation is demonstrating the influence of personal space on communication. B The patient's reaction is not an example of gender influencing communication. C The patient's reaction is not an example of environment influencing communication. Noise, temperature extremes, distractions, and lack of privacy are examples of environmental factors that may influence communication. D Although people do maintain varying distances between each other depending on their culture, the patient's reaction is not an example of sociocultural background influencing communication, as cultural orientation is not mentioned in this situation.

The physician orders 0.125 mg digoxin orally. The medication is available in 0.25 mg. Which of the following is the correct dose to administer to the patient? a. One-half tablet b. One tablet c. Two tablets d. Four tablets

ANS: A Feedback A To calculate this dosage, the nurse should apply a basic formula for calculating medication. Dose ordered/Dose on hand × Amount on hand = Amount to administer. 0.125 mg/0.25 mg × 1 tablet = Number of tablets to administer (0.5 × 1 = 0.5, or a half tablet to be administered). B One tablet is not the correct dosage calculation. C Two tablets is not the correct dosage calculation. D Four tablets is not the correct dosage calculation.

Which of the following is a priority for the nurse in the administration of oral medications and prevention of aspiration? a. Checking for a gag reflex b. Allowing the patient to self-administer c. Assessing the ability to cough d. Using straws and extra water for administration

ANS: A Feedback A To protect the patient from aspiration, the nurse should determine the presence of a gag reflex before administering oral medications. B The nurse should first check for a gag reflex. Then, if possible, the patient should be allowed to self-administer oral medications. C Checking for a gag reflex takes priority over assessing the ability to cough in preventing aspiration. D Straws should be avoided because they decrease the control the patient has over volume intake, which increases the risk of aspiration. Some patients cannot tolerate thin liquids such as water, in which case they should be thickened.

An order is written for 80 mg of a medication in elixir form. The medication is available in 80 mg/tsp strength. Which of the following does the nurse prepare to administer? a. 2 mL b. 5 mL c. 10 mL d. 15 mL

ANS: B Feedback A A 2-mL dosage is incorrect, as 2 mL would equal less than a half-teaspoon (in this case, 32 mg). B The nurse should first change the household measurement to a metric equivalent (5 mL = 1 tsp), and then the nurse should use the formula for calculating a medication dosage. C A 10-mL dosage is incorrect, as 10 mL would equal 2 tsp (in this case, 160 mg). D A 15-mL dosage is incorrect, as 15 mL would equal 3 tsp (in this case, 240 mg).

Which of the following is one of Bowlby's phases of mourning? a. Acceptance b. Reorganization c. Accepting reality of loss d. Emotionally relocating and moving on

ANS: B Feedback A Acceptance is a stage of grief. B Reorganization is one of Bowlby's four phases of mourning. C Accepting the reality of loss is one of Worden's four tasks of mourning. D Emotionally relocating and moving on is one of Worden's four tasks of mourning.

A patient is taught the clinical manifestations of inflammation to allow early detection of a complication of a surgical wound. The patient states, "I will look at the wound four times a day and tell my surgeon if it looks red or swollen." Her statement is an example of what? a. Attitudes b. Application c. Analysis d. Evaluation

ANS: B Feedback A Attitude has to do with affective learning. The patient is not expressing an attitude but is applying new knowledge in a concrete way. B Application involves using abstract, newly learned ideas in a concrete situation. The patient who is taught the clinical manifestations of inflammation and how to assess for signs such as redness or edema is using newly learned information in a concrete manner. C Analysis involves breaking down information into organized parts. The patient is not demonstrating analysis in this situation. D Evaluation is a judgement of the worth of a body of information for a given purpose. This patient is not expressing judgement.

The nurse is performing a physical examination of an older adult patient in an assisted-living facility. On completion of the exam, the nurse compares the results with findings expected for individuals in this age group. Which of the following increases is an expected finding for this patient? a. Tactile responsiveness b. Sensitivity to glare c. Hearing acuity for higher tones d. Thoracic expansion during ventilation

ANS: B Feedback A Increased tactile responsiveness would not be an expected finding in the older adult patient. B A common physiological change in the older adult patient is an increased sensitivity to glare. C An expected physiological change in the older adult patient is a loss of hearing acuity for high-frequency tones (presbycusis). D The older adult has decreased thoracic expansion during ventilation because of musculoskeletal changes.

A patient has been diagnosed with terminal cancer of the liver and is receiving chemotherapy on a medical unit. In an in-depth conversation with the nurse, the patient states, "It can't be happening to me." According to Kübler-Ross, with which of the following is this stage of dying associated? a. Anxiety b. Denial c. Confrontation d. Depression

ANS: B Feedback A No stage of anxiety is found in Kübler-Ross's five stages of dying. B According to Kübler-Ross, the patient is in the denial stage of dying. The patient may act as though nothing has happened, may refuse to believe or understand that a loss has occurred, and may seem stunned, as though it is "unreal" or difficult to believe. C No stage of confrontation is found in Kübler-Ross's five stages of dying. D During depression, the individual may feel overwhelmingly lonely and withdraw from interpersonal interaction. Depression is one of Kübler-Ross's five stages of dying but is not represented by this example.

The nurse works with older adult patients in a wellness-screening clinic on a weekly basis. Which of the following is the best statement made by the nurse to patients in the older adult age group? a. "Your shoulder pain is normal for your age." b. "Regular exercise will maintain and strengthen your functional ability." c. "Don't worry about taking that combination of medications because your doctor has prescribed them." d. "Why don't you begin walking three to four kilometres per day, and we'll evaluate how you feel next week?"

ANS: B Feedback A Shoulder pain is not a normal finding in the older adult. It may indicate a condition such as arthritis. B The primary benefits of exercise include maintaining and strengthening functional ability, and promoting a sense of enhanced well-being. C Periodic and thorough review of all medications being used is important to restrict the number of medications used to the fewest necessary. Concurrent use of medications increases the risk for adverse reactions. D Exercise programs should begin conservatively and progress slowly.

Which of the following reflects an appropriate teaching method for the affective domain of learning? a. Storytelling b. Role playing c. Demonstration d. A question-and-answer session

ANS: B Feedback A Storytelling is an appropriate method for the cognitive learning domain. B Appropriate teaching methods for the affective domain of learning include role playing, group discussion, and one-on-one discussion. C Demonstration is an appropriate method for the psychomotor learning domain. D A question-and-answer session is an appropriate method for the cognitive learning domain.

Which of the following refers to all factors that influence how a message is perceived by other people? a. Symbolic communication b. Metacommunication c. Active expression d. Contextual action

ANS: B Feedback A Symbolic communication is verbal and nonverbal symbolism used to convey meaning. B Metacommunication is a broad term that refers to all factors that influence how a message is perceived by other people. C Active expression is not the term that refers to all factors that influence a message as perceived by other people. D Contextual action is not the term that refers to all factors that influence a message as perceived by other people.

Which of the following is an example of a teaching topic of restoration of health? a. Medication side effects b. Limitations on function c. Screening for common conditions d. Behaviour modification to change a risky behaviour

ANS: B Feedback A Teaching about medications is an example of the topic of optimizing quality of life when functions are impaired. B Limitations on function are an example of a teaching topic of restoration of health. C Screening for common conditions is an example of a health maintenance and promotion-illness prevention teaching topic. D Behaviour modification to change a risky behaviour is an example of a health maintenance and promotion-illness prevention teaching topic.

The nurse is working on the pediatric unit. In preparing to give medications to a preschool-age child, which of the following is an appropriate interaction by the nurse? a. "Do you want to take your medication now?" b. "Would you like the medication with water or juice?" c. "Let me explain about the injection that you will be getting." d. "If you don't take the medication now, you will not get better."

ANS: B Feedback A The child should not be given the option of not taking a medication. B Allowing the child a choice of taking a medication with water or juice may have greater success because the child is involved. C The nurse should explain the procedure to a child using short words and simple language appropriate to the child's level of comprehension. Long explanations may increase a child's anxiety. D The statement, "If you don't take the medication now, you will not get better," is not a motivation for the child to take the prescribed medication. Giving the child a star or token afterward would be more motivating.

Which of the following statements is true regarding cultural beliefs and death? a. The ethical decisions surrounding a patient's death should be based on hospital policy and not culture. b. Maintaining rituals and practices allows a sense of acceptance of the dying process. c. The nurse must decide which cultural practices will be incorporated in care of the dying. d. Regardless of culture, following hospital practices will help focus patient and family on the dying process.

ANS: B Feedback A The nurse should be familiar with policies and procedures, but ethical decisions should be made with an understanding and appreciation of the patient's culture. B Maintaining the integrity of rituals and mourning practices gives families a sense of acceptance of the patient's death and an inner peace. C The nurse must assess the terminally ill patient's and family's wishes for end-of-life care and develop a plan of care by integrating patient culture and spiritual beliefs. D On the contrary, the nurse must assess the terminally ill patient's and family's wishes for end-of-life care and develop a plan of care by integrating patient culture and spiritual beliefs.

The nurse has completed an assessment of the patient and identified the following nursing diagnoses. Which one indicates a need to postpone teaching that was planned? a. Knowledge deficit regarding impending surgery b. Activity intolerance related to pain c. Ineffective management of treatment regimen d. Noncompliance with prescribed exercise plan

ANS: B Feedback A The nursing diagnosis, "Knowledge deficit regarding impending surgery," does not indicate a need to postpone teaching. A knowledge deficit reinforces the need for teaching. B Pain, fatigue, or anxiety can interfere with the ability to pay attention and participate. The nursing diagnosis of "Activity intolerance related to pain" indicates a need to postpone teaching. Teaching can be delayed until the nursing diagnosis is resolved or the health problem is controlled. C The nursing diagnosis of "Ineffective management of treatment regimen" does not indicate a need to postpone teaching. Ineffective management of treatment regimen reinforces the need for teaching. D The nursing diagnosis of "Noncompliance with prescribed exercise plan" does not indicate a need to postpone teaching. The patient who is noncompliant may require further teaching.

The patient receiving an intravenous (IV) infusion of morphine sulphate begins to experience respiratory depression and decreased urine output. How is this effect described? a. Therapeutic b. Toxic c. Idiosyncratic d. Allergic

ANS: B Feedback A The therapeutic effect is the expected or predictable physiological response a medication causes. Respiratory depression and decreased urine output are not the desired (i.e., therapeutic) effects of morphine. B Toxic levels of morphine may cause severe respiratory depression. Toxic effects may develop after prolonged intake of a medication or when a medication accumulates in the blood because of impaired metabolism or excretion. The patient with a decreased urine output is not excreting the morphine. C An idiosyncratic effect occurs when a medication causes an unpredictable outcome, such as when a patient overreacts or underreacts to a medication. This is not an example of an idiosyncratic effect. D When a patient experiences an allergic response to a medication, the medication acts as an antigen, triggering the release of antibodies. The patient may experience itching, urticaria, a rash, or in more severe cases, may have difficulty breathing. This patient's response to morphine is not an example of an allergic effect.

A long-term care facility sponsors a discussion group on the administration of medications. The participants have a number of questions concerning their medications. Which of the following is the most appropriate response by the nurse? a. "Don't worry about the medication's name if you can identify it by its colour and the way it looks." b. "Please feel free to ask your physician why you are receiving the medications that are ordered for you." c. "Remember that the hepatic system is primarily responsible for the pharmacotherapeutics of your medications." d. "Unless you have severe side effects from taking your medications, don't worry about the minor changes in the way you feel."

ANS: B Feedback A The older adult should be taught the names of all drugs being taken, when and how to take them, and the desirable and undesirable effects of the drugs. B The nurse should encourage the older adult to question the physician or pharmacist (or both) about all prescribed drugs and over-the-counter drugs. C The hepatic system is not the only system responsible for the pharmacotherapeutics of medication. Older adults are at risk for adverse reactions because of age-related changes in the absorption, distribution, metabolism, and excretion of drugs. Changes in the gastrointestinal system may affect absorption, distribution may be affected by changes in body composition and by reduced serum albumin levels, and changes in kidney functioning may impair excretion. D The nurse should teach the patient how to avoid adverse side effects and to report them to the care provider if they occur. If the patient is disturbed by minor side effects, it could be an indication of beginning drug toxicity. Another possibility is that the patient may become noncompliant with the medication because of a dislike of how the side effects make him or her feel.

The nurse is aware of the patient's zones of personal space when planning interactions. Which of the following zones of personal space and touch is the one that extends the greatest amount of distance from an individual? a. Personal zone b. Social zone c. Consent zone d. Vulnerable zone

ANS: B Feedback A The personal zone extends from 45 cm to 1 m. B The social zone extends the greatest amount of distance from an individual in personal space and touch. It is a distance of 1 to 4 m. Permission is not needed for touch in the social zone. C The consent zone of touch requires permission. D The vulnerable zone is in the consent zone of touch. Because the vulnerable zone implies that special care is needed, permission is required.

The nurse will often display empathy in communication with patients. Which of the following responses by the nurse best conveys empathy? a. "Good morning. How did you sleep last night?" b. "I can understand your concern about learning to inject yourself." c. "Do you mean you would like to talk to the new family nurse practitioner?" d. "Can you describe what the pain in your abdomen feels like?"

ANS: B Feedback A The response, "Good morning. How did you sleep last night?", is asking a question. It does not convey empathy. B Empathy is the ability to understand and accept another person's reality, to perceive feelings accurately, and to communicate this understanding to others. C The response, "Do you mean you would like to talk to the new family nurse practitioner?", is asking a question to clarify the patient's meaning. It does not convey empathy. D The response, "Can you describe what the pain in your abdomen feels like?", is asking a relevant question that may focus on a particular topic. However, it is not an example of empathy.

The nurse is teaching a group of patients who have recently been diagnosed with heart disease. The nurse arranges the patients in pairs and asks them to plan a low-fat meal. This is an example of which of the following teaching strategies? a. Analogy b. Simulation c. Demonstration d. Role playing

ANS: B Feedback A This is not an example of an analogy. B This is an example of simulation. Simulation helps teach problem solving, application, and independent thinking. C This is not an example of a demonstration. D This is not an example of role playing.

The nurse assesses the patient's readiness to learn insulin injection sites. Many factors are assessed before teaching. Which of the following factors should the nurse assess first? a. Previous knowledge level of the patient b. Willingness of the patient to learn the injection sites c. Financial resources available to the patient for the equipment d. Intelligence and developmental level of the patient

ANS: B Feedback A To determine learning needs, the nurse should assess the patient's previous knowledge level. However, this would not be the most important factor for the nurse to assess first. B If a person does not want to learn, it is unlikely that learning will occur. Motivation is the first factor the nurse should assess before teaching. C Assessing a patient's financial resources for obtaining equipment is important; however, it is not the most important factor for the nurse to assess first. D Assessing the patient's physical and cognitive ability to learn is important. However, it is not the most important factor for the nurse to assess first.

The patient has been informed that he can be discharged once he can irrigate his colostomy independently. The patient asks the nurse to observe his irrigation technique. Which of the following learning motives is the patient displaying? a. Physical motive b. Social motive c. Task mastery d. Evaluation stance

ANS: C Feedback A A physical motive may be seen in the patient who has a desire to maintain or improve health. B A social motive is the need for connection, social approval, or self-esteem. C Task mastery motives are driven by desire for achievement. The patient who must demonstrate irrigating his colostomy independently to be discharged is displaying the learning motive of task mastery. D An evaluation stance would involve the nurse determining whether the outcomes of the teaching-learning process met the patient's goal. Evaluation is not a learning motive.

The patient is nauseated, has been vomiting for several hours, and needs to receive an antiemetic medication. The nurse recognizes that which of the following statements is true about this medication? a. An enteric-coated medication should be given. b. Medication will not be absorbed as easily because of the nausea. c. A parenteral route is the route of choice. d. A rectal suppository must be administered.

ANS: C Feedback A An enteric-coated medication is given orally. Because the patient is vomiting, the oral route should not be used. B Nausea does not affect the rate of absorption. C The parenteral route provides a means of administration when oral medications are contraindicated. Onset of action is quicker, and there is less cause for embarrassment than with a rectal suppository. D It is inaccurate to state that a rectal suppository must be administered. A rectal suppository is one option, but there is the disadvantage that insertion often causes embarrassment for the patient. It is contraindicated if rectal bleeding is present or if the patient had rectal surgery. Stool in the rectum can impair absorption.

For older adults, a number of health-related concerns should be addressed. The nurse incorporates this information to meet the needs of the older adult patient. Which of the following statements accurately reflects data that the nurse should use in planning care? a. Approximately 50% of adults older than 65 years have two chronic health problems. b. Cancer is the most common cause of death among older adults. c. The nutritional needs of older adults are affected by older adults' levels of activity and by clinical conditions. d. Adults older than 65 years make up the lowest percentage of users of prescription medications.

ANS: C Feedback A Approximately 80% of older adults living at home have at least one chronic health condition, with arthritis, hypertension, heart disease, vision impairment, and diabetes mellitus being the most common in noninstitutionalized older adults. B Heart disease is the leading cause of death in older adults. C The nutritional needs of older adults are affected by their levels of activity and by clinical conditions. In assessing nutrition in older adults, the nurse needs to consider sedentary activity, therapeutic diets, recovery from surgery, and dementia. D It is untrue that adults older than 65 years make up the lowest percentage of users of prescription medications. Older adults account for 12% of the population but use as much as 40% of prescription medication; they make up the highest percentage of users of prescription medication.

Which of the following is a positive way to assist the nurse in coping with the death of a patient? a. Avoiding attending the patient's funeral b. Avoiding being present at the time of death c. Writing a letter of sympathy to the family d. Focusing on providing palliative care to the next patient

ANS: C Feedback A Attending the funeral, rather than avoiding attendance, is a positive way to cope. B By being present at the time of the patient's death, the nurse is able to let go. C Writing a letter of sympathy to the family can prove helpful for some nurses to cope with a patient's death. D Focusing on the next patient avoids dealing with the nurse's feelings of loss related to the death of the current patient.

Which of the following is a procedural guideline for care of the body after death? a. Remove dentures. b. Maintain open eyes. c. Apply name tags, according to agency policy. d. After the family is gone, discard items found in the patient's room.

ANS: C Feedback A Dentures are to be inserted into the mouth, not removed. B Eyes are to be closed rather than opened. C Procedural guidelines for care of a body after death include applying name tags according to protocol, such as on the wrist, the right big toe, or outside a shroud. D Any items found in the room after the family leaves are to be kept, and the family is to be contacted for item pickup.

An older woman reports that she involuntarily releases urine when she coughs or sneezes. What is this type of incontinence called? a. Functional incontinence b. Reflex incontinence c. Stress incontinence d. Total incontinence

ANS: C Feedback A Functional incontinence is the inability of a usually continent person to reach the toilet in time. B Reflex incontinence is an involuntary loss of urine at somewhat predictable intervals when a specific bladder volume is reached. C Stress incontinence is an involuntary release of urine that occurs on sneezing, coughing, or lifting an object, and is a result of a weakness of the perineal and bladder muscles. D In total incontinence, an individual experiences continuous and unpredictable loss of urine.

Which one of the following nutritional deficiencies is most common for an older adult with reduced financial resources living in a remote rural community? a. Fat b. Salt c. Protein d. Carbohydrate

ANS: C Feedback A Older adults are encouraged to reduce fat intake. B Older adults are encouraged to reduce salt intake. C Protein is often deficient in aging adults with limited income and limited access to grocery stores. D Carbohydrate intake is not related to limited financial resources, as carbohydrate-rich foods such as pasta are among the most economical foods to purchase.

In which of the following communication techniques is the nurse making an error when he or she discusses the patient's follow-up dietary needs immediately after the surgery when the patient is experiencing discomfort? a. Pacing b. Intonation c. Timing and relevance d. Denotative meaning

ANS: C Feedback A Pacing has to do with the speed of conversation. The nurse's decision to discuss dietary needs immediately after the patient's surgery is not an example of an error in pacing. B Intonation is the tone of voice used. The nurse's decision to discuss dietary needs immediately after the patient's surgery is not an example of an error in intonation. C Discussing follow-up dietary needs immediately after surgery when the patient is experiencing discomfort is an error in timing and relevance. The patient is less likely to be able to pay attention and comprehend instruction when feeling pain, and immediately after surgery, discussing follow-up dietary needs would seem irrelevant. D Denotative meaning occurs when a single word can have several meanings. The nurse's decision to discuss dietary needs immediately after the patient's surgery is not an example of an error in denotative meaning.

The physician has ordered that the patient have eye drops administered daily to both eyes. On which part of the eye should eye drops be instilled? a. Cornea b. Outer canthus c. Lower conjunctival sac d. Opening of the lacrimal duct

ANS: C Feedback A The cornea is very sensitive. Drops instilled onto the cornea would stimulate the blink reflex. B The outer canthus would not hold the eye drop, and medication would be wasted; nor would the medication be distributed evenly across the eye. C Eye drops should be instilled into the lower conjunctival sac. The conjunctival sac normally holds one or two drops and provides even distribution of medication across the eye. D The opening of the lacrimal duct is not the correct site for eye drops to be instilled. It would not provide even distribution of drops across the eye, and medication would most likely be wasted because this area could not contain the eye drops.

The student nurse reads the order to give a 1-year-old patient an intramuscular (IM) injection. Which of the following is the appropriate and preferred muscle to select? a. Deltoid b. Dorsogluteal c. Ventrogluteal d. Vastus lateralis

ANS: C Feedback A The deltoid muscle is not developed enough for an IM injection in the 1-year-old patient. B The dorsogluteal site is not recommended because of the risk of the needle hitting the sciatic nerve. C Research that has investigated complications associated with IM injection sites indicates that the ventrogluteal site is the preferred site for most injections given to adults and children. D The vastus lateralis is a preferred site for infants younger than 12 months.

The physician has ordered 6 mg morphine sulphate every three to four hours prn for a patient's postoperative pain. The unit dose in the medication dispenser has 15 mg in 1 mL. How much solution should the nurse give? a. 1.5 mL b. 1.3 mL c. 0.4 mL d. 1.25 mL

ANS: C Feedback A The dosage calculation of 1.5 mL is incorrect. B The dosage calculation of 1.3 mL is incorrect. C The nurse should use the formula to calculate a drug dosage: Dose ordered/Dose on hand × Amount on hand = Amount to administer (6 mg/15 mg × 1 mL) = 0.4 mL. D The dosage calculation of 1.25 mL is incorrect.

A medication is prescribed for the patient and is to be administered by IV bolus injection. Which of the following is a priority for the nurse before administering the medication via this route? a. Set the rate of the IV infusion. b. Check the patient's mental alertness. c. Confirm placement of the IV line. d. Determine the amount of IV fluid to be administered.

ANS: C Feedback A The nurse should first confirm placement of the IV line. B The nurse should first confirm placement of the IV line before administering a medication by the IV route. The patient's mental alertness may be something the nurse monitors after medication administration. C A priority for the nurse before the administration of medication via the IV route is to confirm placement of the IV line. Confirming the placement of the IV catheter and the integrity of the surrounding tissue ensures that the medication is administered safely. D The nurse should first confirm placement of the IV line before administering any IV fluids.

The nurse is assigned to a patient who was recently diagnosed with a terminal illness. During morning care, the patient asks about organ donation. How should the nurse respond? a. Have the patient first discuss the subject with the family. b. Suggest that the patient delay making a decision at this time. c. Assist the patient to obtain the necessary information to make this decision. d. Contact the physician so that consent can be obtained from the family.

ANS: C Feedback A The nurse should provide the patient with information with which to make such a decision. Although the nurse may suggest that the patient discuss the subject with the family after having obtained information, it is up to the patient to discuss the subject with his or her family. B The nurse should respect the patient and provide the necessary information for him or her to make a decision, rather than dismissing the patient's question. C No topic that a dying patient wishes to discuss should be avoided. The nurse should respond to questions openly and honestly. As patient advocate, the nurse should assist the patient to obtain the necessary information to make this decision. D It is not necessary to contact the physician or the family for consent for organ donation if the patient is capable of making this decision.

After the nurse has administered ear drops to the patient's left ear, how should the nurse position the patient? a. Prone b. Upright c. Right lateral d. Dorsal recumbent with hyperextension of the neck

ANS: C Feedback A The prone position is not recommended after administration of ear drops. B The upright position is not recommended after ear drop administration. The ear drops would run out of the ear canal. C The patient should remain in the side-lying position, in this case the right lateral position, for two to three minutes after the ear drops are administered. D The dorsal recumbent position with the neck hyperextended is not recommended after the administration of ear drops.

Which of the following statements from a patient does the nurse evaluate as an indication that the patient is not ready to learn at this time? a. "I need to understand more about the reason for the colostomy." b. "I will find out when the support group meets." c. "There's no sense in showing me. I'm too sick right now." d. "Tell me if I am doing this correctly."

ANS: C Feedback A The statement, "I need to understand more about the reason for the colostomy", indicates that the patient is ready to learn and desires to find out more to gain understanding. B The statement, "I will find out when the support group meets", indicates that the patient is willing to learn. C Readiness to learn is related to the stage of grieving. The patient's response, "There's no sense in showing me. I'm too sick right now," demonstrates anger. The patient is unwilling to learn at this time. The patient has not yet reached the acceptance state of grieving in which learning can occur. D The patient who requests feedback is expressing readiness to learn.

Different topics are presented in the information sessions that are held in the outpatient clinic. In planning for a session on health maintenance and promotion-illness prevention, which of the following topics should the nurse select? a. Use of assistive devices, such as canes b. Self-help devices for patients who have had a cerebrovascular accident c. Stress management techniques for working parents d. Environmental alterations for patients in wheelchairs

ANS: C Feedback A Use of assistive devices such as canes is not a health maintenance-illness prevention topic. The topic is coping with impaired function. B Self-help devices for patients who have suffered a cerebrovascular accident are not a health maintenance-illness prevention topic. The topic is coping with impaired function. C Stress management techniques for working parents are an appropriate topic for health maintenance-illness prevention. D Environmental alterations for patients in wheelchairs are not a health maintenance-illness prevention topic. The topic is coping with impaired function.

The newly graduated nurse is assigned to his or her first dying patient. How can the nurse best prepare to care for this patient? a. Complete a course dealing with death and dying. b. Control his or her own emotions about death. c. Draw on the experience of the death of a loved one. d. Develop an understanding of his or her own feelings about death.

ANS: D Feedback A Although coursework on death and dying may add to the nurse's knowledge base, it does not best prepare the nurse for caring for a dying patient. The nurse needs to have an awareness of his or her own feelings about death first, as death can raise many emotions. B Being able to control one's own emotions is important; however, it is unlikely that the nurse would be able to do so if he or she has not first developed a personal understanding of his or her own feelings about death. C Experiencing the death of a loved one is not a prerequisite to caring for a dying patient. Experiencing death may help an individual mature in dealing with loss, or it may bring up many negative emotions if complicated grief is present. The nurse is best prepared by first developing an understanding of his or her own feelings about death. D When caring for patients experiencing grief, it is important for the nurse to assess his or her own emotional well-being and to understand his or her own feelings about death. The nurse who is aware of his or her own feelings will be less likely to place personal situations and values before those of the patient.

On which of the following are calculations most precisely based to determine proper drug dosages for children? a. The child's weight b. The child's height c. The child's age d. The child's body surface area

ANS: D Feedback A Drug calculations are not most precise when made on the basis of a child's weight. Height and weight do not always correlate with the maturity of the child's organs, such as the liver, for metabolizing a drug. B Drug calculations are not most precise when made on the basis of a child's height. C Drug calculations are not most precise when made on the basis of a child's age. Children vary widely in size and maturity for chronological age. D The most accurate method of calculating pediatric doses is based on a child's body surface area.

The nurse recognizes that anticipatory grieving can be most beneficial to a patient or family for which of the following reasons? a. It can be done in private. b. It can be discussed with others. c. It can promote separation of the ill patient from the family. d. It allows time to say goodbye and complete life affairs before death.

ANS: D Feedback A It is not most beneficial for grieving to take place only in private. It is important for grief to be acknowledged by others, and for those grieving to be able to receive the support of others in the grieving process. B Anticipatory grieving can be discussed with others in most circumstances. However, anticipatory grief may be disenfranchised grief as well, meaning it cannot always be openly acknowledged, socially sanctioned, or publicly shared, such as grief over the death of a partner with acquired immune deficiency syndrome. The discussion of grief with others can also take place with normal grief, after the loss has occurred. Anticipatory grieving is unique from normal grieving in that it allows time for "letting go" before the death occurs. C Anticipatory grief is the process of disengaging or "letting go" that occurs before an actual loss or death has occurred. The benefit is not the separation of the ill patient from the family as much as it is the process of being able to say goodbye, to put life affairs in order, and as a result, this type of grieving can help a patient or family to progress to a higher emotional state. D The benefit of anticipatory grief is that it allows time for "letting go"; the dying patient and his or her loved ones are able to say goodbye and complete life affairs before the actual death or loss occurs.

An industrial nurse is planning to give an informative talk on hypertension to employees in honour of Heart Month. He plans to teach individuals how to take their own blood pressure. What information is important for the nurse to obtain from the planning committee before this presentation? a. Specific ages of all of the people involved b. Names of employees who are married c. Number of employees with high blood pressure d. Type of room available and number of participants

ANS: D Feedback A Knowing the specific ages of all of the people involved is not as important for providing education on how to take a blood pressure reading as is providing an environment conducive to learning. B It is not necessary to know the names of employees who are married to teach individuals how to take their own blood pressure. C Whether or not employees have high blood pressure should not be as important to the teacher as providing an environment conducive to learning. Having high blood pressure may be a motivating factor for the employees to learn how to take their own blood pressure because of its personal relevance. D The number of persons being taught, the need for privacy, and the room temperature, lighting, noise, ventilation, and furniture are important factors when choosing the setting. The ideal setting helps the patients to focus on the learning task.

Which of the following is the primary concern of the nurse in providing care to a dying patient? a. Promoting optimism in the patient and being a source of encouragement b. Intervening in the patient's activities of daily living to allow the patient to focus on his or her emotional state c. Allowing the patient to be alone and expecting isolation on the part of the dying person d. Selecting interventions designed to maintain the patient's dignity and self-esteem

ANS: D Feedback A Optimism should not be the primary focus when caring for the dying patient. The nurse should promote the patient's self-esteem and allow the patient to die in comfort and with dignity. B The patient should be allowed to make choices and perform as many activities of daily living independently as possible. This allows the patient to maintain self-esteem and dignity. C The patient does not need to be left alone. The presence of the nurse or the family may indicate to the patient that he or she is being cared for and is worthy of attention. D The focus in planning nursing care is to promote self-esteem and dignity by taking a therapeutic stance that conveys respect for the patient as a whole person, with feelings, accomplishments, and passions independent of the illness experience.

According to Erikson, which of the following is a developmental task for the older adult? a. Accepting cognitive decline b. Redefining the relationship with one's spouse c. Changing living arrangements for security d. Adjusting to decreasing health and physical strength

ANS: D Feedback A Redefining relationships with adult children, not one's spouse, is a developmental task. B Maintaining satisfactory living arrangements, not necessarily changing them for security, is a developmental task. C Accepting cognitive decline is not a developmental task for the older adult. D Adjusting to decreasing health and physical strength is a developmental task for the older adult.

The nurse selects a variety of teaching methods to use with patients. Which one of the following methods should the nurse use with a toddler? a. Role playing b. Problem solving c. Independent learning d. Simple explanations and pictures

ANS: D Feedback A Role playing is an appropriate teaching method for the preschooler. B Problem solving is an appropriate teaching method for the adolescent. C Independent learning is best used as a teaching method for the young or middle-aged adult. D Effective teaching methods for a toddler include simple explanations and picture books that describe a story of children in a hospital or clinic.

Which of the following would be an appropriate method of communicating with an older adult who has a communication barrier? a. Shout. b. Use elderspeak. c. Speak at a very slow rate. d. Allow time for the patient to respond.

ANS: D Feedback A Shouting is not an appropriate communication technique, as it may distort sound and be misinterpreted as anger. B Elderspeak is condescending baby talk and should be avoided. C Speaking at a very slow rate is not an appropriate communication technique; the nurse should speak clearly at a moderate rate. D One tip for improved communication with older adults who have communication barriers is to allow time for the patient to respond. Do not assume the patient is being uncooperative if he or she makes no response or offers a delayed response.

The nurse is preparing to assist the patient in the end stage of her life. How should the nurse provide comfort for the patient who is showing fatigue? a. Spend more time with the patient. b. Limit the use of analgesics. c. Provide larger meals with more seasoning. d. Determine valued activities, and schedule rest periods.

ANS: D Feedback A Spending more time with the patient conveys caring and allows verbalization, but it is not the best way to promote comfort for a fatigued patient. B The use of analgesics should not be limited. Controlling the terminally ill patient's level of pain is a primary concern in promoting comfort. C Nausea, vomiting, and anorexia may increase the terminally ill patient's likelihood of inadequate nutrition. The nurse should serve smaller portions and bland foods, which may be more palatable. D To promote comfort in the terminally ill patient, the nurse should help the patient to identify values or desired tasks, and then help the patient to conserve energy for those tasks.

An order is written for meperidine (Demerol), 500 mg IM q3-4h prn for pain. The nurse recognizes that this is significantly more than the usual therapeutic dose. Which of the following actions should the nurse take? a. Give 50 mg IM as it was probably intended to be written. b. Refuse to give the medication, and notify the nurse manager. c. Administer the medication, and watch the patient carefully. d. Call the prescriber to clarify the order.

ANS: D Feedback A The nurse cannot independently change a physician's orders. The nurse would have to call the prescriber and receive the order for the change. B The nurse should first call the prescriber and clarify the order. If the prescriber does not change the order, the nurse may then refuse to give the medication and notify the nurse manager. C The nurse could be held accountable for administering an ordered medication that is obviously inappropriate for the patient. D The nurse should question the order if the written order is illegible or if the dose seems unusually low or high. The nurse should call the prescriber to clarify the order.

In performing a physical assessment for an older adult patient, the nurse anticipates finding an increase in which one of the following, representing a normal physiological change of aging? a. Perspiration b. Audio pitch discrimination c. Salivary secretions d. Airway resistance

ANS: D Feedback A The older adult would be expected to have decreased perspiration and drier skin because of glandular atrophy (oil, moisture, sweat glands) in the integumentary system. B A normal physiological change of the older adult related to hearing is a loss of acuity for high-frequency tones (presbycusis). C The older adult would be expected to have a decrease in saliva. D Normal physiological changes of aging include increased airway resistance in the older adult.

The patient is to receive heparin by injection. Where does the nurse prepare to inject this medication? a. In the patient's scapular region b. In the patient's vastus lateralis c. In the patient's posterior gluteal area d. In the patient's abdomen

ANS: D Feedback A The scapular areas may be used for subcutaneous injections, but it is not a recommended site for heparin injections. B The vastus lateralis is used for intramuscular injections, not subcutaneous injections. C The posterior gluteal site is not recommended for heparin injections. D The site most frequently recommended for heparin injections is the abdomen.

Which patient zone of touch would be demonstrated when the nurse is administering eye drops to a patient? a. Social b. Consent c. Intimate d. Vulnerable

ANS: D Feedback A The social zone includes hands, arms, shoulders, and back. B The consent zone includes the mouth, wrists, and feet. C The intimate zone includes the genitalia and the rectum. D When administering eye drops, the nurse must touch the patient`s face. The vulnerable zone of touch involves the face, neck, and the front of the body; this zone requires consent and special care.

The nurse has established an objective for a patient who has been unable to void. The patient's intake will be at least 1000 mL between 0700 hours and 1530 hours. Which one of the following indicates successful feedback from the patient? a. The patient voids at least 1000 mL during the shift. b. The patient verbalizes abdominal comfort without pressure. c. The patient has adequate intake and output. d. The patient drinks 240 mL of fluid five or six times during the shift.

ANS: D Feedback A Voiding at least 1000 mL during the shift is not the objective. The objective is to have the patient drink at least 1000 mL during the designated period. B Verbalizing abdominal comfort without pressure is not an evaluation of the objective regarding specific fluid intake. C Having adequate intake and output is not accurate feedback indicating success. The term adequate is not quantified. D The nurse evaluates success by observing the patient's performance of each expected behaviour. Feedback indicating success in this situation is the patient drinking 240 mL of fluid five or six times during the shift. This would total a fluid intake of 1200 to 1440 mL, meeting the objective of at least 1000 mL during the designated period.

During the assessment phase of the nursing process, the nurse may uncover data that help to identify communication problems. Which of the following is an example of this type of information? a. Extreme dyspnea or shortness of breath b. Urinary frequency and pain c. Chronic stomach pain d. Lack of appetite

ANS: A Feedback A An extremely breathless person must use oxygen to breathe rather than to speak, which would interfere with that person's ability to speak. B Urinary frequency may interrupt conversation but is not a communication problem. C Chronic stomach pain would not be a communication problem. The patient with chronic pain is, to some degree, accustomed to the pain. D A lack of appetite is not a communication problem.

The nurse is in the process of conducting an admission interview with the patient. At one point in the discussion, the patient has provided information that the nurse would like to clarify. Which of the following responses indicate that the nurse is using the technique of clarification? a. "I'm not sure that I understand what you mean by that statement." b. "The electrocardiogram records information about your heart's electrical activity." c. "Let's look at the problem you have had with your medication at home." d. "What's your biggest concern at the moment?"

ANS: A Feedback A Clarifying exists when the nurse checks whether understanding is accurate by restating an unclear message to clarify the sender's meaning, or by asking the other person to restate the message, explain further, or give an example of what the person means. The response, "I'm not sure that I understand what you mean by that statement," indicates that the nurse wants to clarify what the patient is saying so that he or she can have an accurate understanding of what the patient means. B The statement, "The electrocardiogram records information about your heart's electrical activity," is an example of providing information, not clarification. C The statement, "Let's look at the problem you have had with your medication at home," is an example of focusing, not clarification. D The question, "What's your biggest concern at the moment?", is an example of sharing empathy, not of clarification.

Nursing interventions may be categorized based on the degree of nursing autonomy. Which one of the following is an example of a nurse-initiated intervention? a. Providing client teaching b. Administering medication c. Ordering a computed tomography scan d. Referring a client to physiotherapy

ANS: A Feedback A Client teaching is an example of a nurse-initiated intervention. B Administering medication is a physician-initiated intervention. C Ordering a computed tomography scan is a physician-initiated intervention. D Referring a client to physiotherapy is a collaborative intervention.

What is the primary factor that distinguishes a professional nurse's care from care provided by ancillary nursing staff? a. Critical thinking b. Years of education c. Professional licensure d. Complexity of the task

ANS: A Feedback A Clinical decision making separates the professional nurse from technical personnel. The professional nurse is responsible for actions that require critical thinking decision making. B Although advanced education is a distinction, the primary factor regarding patient care is that the professional nurse is responsible for actions that require critical thinking decision making. C Although licensure is a distinction, the primary factor regarding patient care is that the professional nurse is responsible for actions that require critical thinking decision making. D Although complexity is a distinction, the primary factor regarding patient care is that the professional nurse is responsible for actions that require critical thinking decision making.

The nurse seeks to organize the data obtained from the client in a logical manner. What is the term used to describe this organization, which identifies relations between factors and symptoms in the database? a. Clustering data b. Validating data c. Formulating a problem statement d. Performing a peer review

ANS: A Feedback A Clustering data means that the nurse organizes the information obtained into meaningful clusters. A cluster is a set of signs or symptoms grouped together in a logical order. When clustering data, the nurse identifies relations between factors and symptoms. B Validating data means that the nurse compares the data obtained with another source to ensure its accuracy. C After validating data and clustering data, the nurse may formulate a problem statement, usually in the form of a nursing diagnosis. D Peer review is the evaluation of the quality of the work effort of an individual by his or her peers.

In documentation of nursing care plans, how do critical pathways differ from traditional nursing care plans? a. Multidisciplinary approach b. Nursing interventions c. Client outcomes d. Client assessment

ANS: A Feedback A Critical pathways are multidisciplinary. They allow staff from all disciplines, such as medicine, nursing, pharmacy, and social work, to develop integrated care plans for a projected length of stay or number of visits for clients with a specific case type. B Nursing interventions are included in critical pathways and in the traditional nursing care plan. C Client outcomes are included in both critical pathways and traditional nursing care plans. D Client assessment is necessary for developing and evaluating critical pathways and traditional nursing care plans.

The goal identified in the nursing care plan is that "The client will be able to wash himself after a four-week therapy session." When should the nurse evaluate the client's progress toward this goal? a. On an ongoing basis b. At the end of four weeks c. Weekly d. Before the client's discharge

ANS: A Feedback A Evaluation is ongoing whenever the nurse has contact with the client. B Evaluation should be ongoing. If the nurse waits four weeks to evaluate the effects of the nursing care, the condition could have deteriorated. Evaluating the client on an ongoing basis ensures that the nurse can adjust nursing care to his needs. C Evaluation should be ongoing. The nurse must evaluate more often than weekly in order to meet the needs of the client. D The nurse must evaluate on an ongoing basis to assess if the needs of the client are being met.

What is the second component of critical thinking in the "critical thinking model"? a. Experience b. Competencies c. Specific knowledge d. Diagnostic reasoning

ANS: A Feedback A Experience is the second component of critical thinking in the "critical thinking model." B The third component of the "critical thinking model" is competencies. C Specific knowledge base is the first component of the "critical thinking model." D Diagnostic reasoning is a specific critical thinking competency in clinical situations.

The nurse is documenting on the patient's record and notes that he or she has made an error. What action should the nurse take? a. Draw a line through the error, and initial and date it. b. Erase the error, and write over the material in the same spot. c. Use a dark-coloured marker to cover the error, and continue immediately after that point. d. Footnote the error at the bottom of the page, including initials and the date

ANS: A Feedback A If the nurse has made an error in documentation, he or she should draw a single line through the error, write the word "error" above it, and sign his or her name or initials. Then the nurse should record the note correctly. B The nurse should not erase, apply correction fluid to, or scratch out errors made while recording because charting then becomes illegible. Entries should be made only in ink so that they cannot be erased. C Using a dark-coloured marker to cover the error and continuing immediately after that point is not the correct action. It might thus appear as if the nurse were attempting to hide something or deface the record. D Footnotes are not used in nursing documentation.

Which of the following processes is an example of indirect care? a. Documentation b. Medication administration c. Catheterization d. Grief counselling

ANS: A Feedback A Indirect care interventions are treatments performed away from the client but on behalf of the client or group of clients. Examples of indirect care include actions aimed at managing the client's environment (e.g., safety and infection control, documentation, and interdisciplinary collaboration). B Medication administration is an example of direct care. C Catheterization is an example of direct care. D Grief counseling is an example of direct care.

The nurse enters the room of a patient who has a history of heart disease. On looking at the patient, the nurse feels that something is "not right" with the patient, and proceeds to take the vital signs. What is this nurse acting on? a. Intuition b. Reflection c. Knowledge d. Scientific method

ANS: A Feedback A Intuition is part of the clinical judgement the nurse is using in this situation. In making a clinical judgement, the nurse considers the context of the situation and relies on analytical processes, intuition, and narrative thinking. As the nurse reflects on actions taken, clinical learning occurs, which contributes to future clinical judgements. B Reflection is the process of purposefully thinking back or recalling a situation to discover its purpose or meaning. C Knowledge of the nurse includes information and theory from the basic sciences, humanities, behavioural sciences, and nursing. D Scientific method is an approach to seeking the truth or verifying that a set of facts agrees with reality.

A number of different types of nursing interventions may be incorporated into the plan of care. Which of the following interventions is an example of a specific life-saving measure that the nurse may implement? a. Restraining a violent client b. Administering analgesics c. Initiating stress-reduction therapy d. Teaching the client how to take his or her pulse

ANS: A Feedback A Restraining a violent client is an example of a life-saving measure to protect the client. The purpose of a life-saving measure is to restore physiological or psychological equilibrium. B Administering analgesics is an example of a physical care technique. It is not a life-saving measure. C Initiating stress-reduction therapy is an example of a counselling technique. D Teaching the client how to take his or her pulse is an example of the nursing intervention of teaching. The focus is for the client to obtain new knowledge or psychomotor skills.

A slight hematoma has developed on the patient's left forearm. The nurse labels the problem as an infiltrated intravenous (IV) line. The nurse elevates the forearm. The patient states, "My arm feels better." Which of these is documented as the "R" in the data-action-response (DAR) notes of focus charting? a. "My arm feels better." b. "Slight hematoma on left forearm" c. "Infiltrated IV line" d. "Elevation of left forearm"

ANS: A Feedback A The "R" in the data-action-response (DAR) documentation of focus charting is the response by the patient. In this case, the nurse would document, "Patient states, 'My arm feels better.'" B "Slight hematoma on left forearm" is the "D" in DAR, referring to data in focus charting. C "Infiltrated IV line" is the "D" in DAR, referring to data in focus charting. D "Elevation of left forearm" is the "A" in DAR, describing the action or nursing intervention in focus charting.

An alert, oriented adult client is admitted to the medical centre for diagnostic testing. What is the primary source of information when completing an assessment for this client? a. Client b. Physician c. Family member d. Experienced nurse on the unit

ANS: A Feedback A The client is the primary source of information. The client who is conscious and alert, and able to answer questions correctly can provide the most accurate information about his or her own health care needs, lifestyle patterns, present and past illnesses, perception of symptoms, and changes in activities of daily living. B The physician may have knowledge of the client's medical problem, but the client is the primary source of information for completing an assessment. C Family members can be interviewed as primary sources of information about infants or children and critically ill, mentally handicapped, disoriented, or unconscious clients. Usually, however, they are secondary sources of information and can confirm findings provided by the client. The client in this situation is capable of being the primary source of information. D An experienced nurse on the unit may offer insight into a client's health care needs and care but is not the primary source of information for a client assessment.

The nurse is working with a client who is being prepared for a diagnostic test this afternoon. The client tells the nurse that she wants to have her hair shampooed. Which of the following is the most appropriate label with regard to assigning a priority for the client's request? a. Low priority b. An unmet need c. Intermediate priority d. A safety and security need

ANS: A Feedback A The client's request would be of low priority because it is not directly related to a specific illness or prognosis. B "An unmet need" is not the most appropriate label for the client's request. C The client's request is not an intermediate priority. An intermediate priority is one that involves the nonemergency, non-life-threatening needs of the client. D The client's request is not a safety and security need; the outcome does not threaten her well-being.

The nurse decides to administer tablets of acetaminophen (Tylenol) instead of the ibuprofen she has been giving one of her orthopedic patients, in accordance with the prescriber's order. Which step of the nursing process does this address? a. Assessment b. Nursing diagnosis c. Planning d. Implementation

ANS: D Feedback A Assessment involves the gathering of data. B When formulating a nursing diagnosis, the nurse critically examines and analyzes the data, and then identifies the patient's response to a problem. The nurse may then determine priorities. C Planning involves establishing goals and expected outcomes of care. D Taking appropriate action demonstrates the implementation step of the nursing process.

The nurse has a multiple patient assignment on the surgical unit. When beginning the shift, the nurse needs to determine which postoperative patient should be seen first. Which one of the following patients should the nurse see first? a. The patient is reported as having a BP of 90/50 mm Hg. b. The patient received medication for pain ten minutes ago. c. The patient needs to be out of bed and ambulating. d. The patient requires instructions for wound care.

ANS: A Feedback A The nurse who assigns priorities to action and determines to see this patient first because of a lower than normal BP for a postoperative patient is using scientifically and practice-based criteria for making a clinical judgement. This is an example of following standards. The nurse uses criteria such as the clinical condition of the patient, Maslow's hierarchy of needs, and risks involved in treatment delays to determine which patients have the greatest priority for care. B The patient who received medication for pain ten minutes ago is not the priority. C The patient who needs to be out of bed and ambulating is not the priority. D The patient who requires instructions for wound care is not the priority.

What is the primary purpose of the nursing evaluation process? a. To determine the effectiveness of the nursing care provided b. To identify interventions that are ineffective in achieving client goals c. To establish the progress the client is making toward health and wellness d. To critique the nurse's ability to implement appropriate nursing interventions

ANS: A Feedback A The primary purpose of the nursing evaluation process is to determine the effectiveness of nursing care. B The option, "To identify interventions that are ineffective in achieving client goals," is an example of evaluation but does not reflect the primary purpose of nursing evaluation. C The option, "To establish the progress the client is making toward health and wellness," is an example of evaluation but does not reflect the primary purpose of nursing evaluation. D The option, "To critique the nurse's ability to implement appropriate nursing interventions," is an example of evaluation but does not reflect the primary purpose of nursing evaluation.

Which of the following terms describes an unexpected occurrence when the unit documentation is a critical pathway? a. Incident b. Variance c. Deviation d. Charting by exception

ANS: B Feedback A "Incident" is not the term used for an unexpected occurrence when using critical pathways. B Critical pathways eliminate the need for nurses' notes, flow sheets, and nursing care plans because the pathway document integrates all relevant information. Unexpected occurrences, unmet goals, and interventions not specified within the clinical pathway time frame are called variances. C "Deviation" is not the term used for an unexpected occurrence when using critical pathways. D "Charting by exception" is a type of standardized charting and is not the term used for an unexpected occurrence when using critical pathways.

Which of the following denotes a principle for rational thought? a. Code of ethics b. Intellectual standards c. Nursing judgements d. Complex critical thinking

ANS: B Feedback A A code of ethics is not a principle for rational thought. B An intellectual standard is a guideline or principle for rational thought. C Nursing judgements are not a principle for rational thought. D Complex critical thinking is not a principle for rational thought; rather, it is adopted as you advance in your nursing practice.

An older Chinese woman refuses to perform the range-of-motion and breathing exercises required after a surgical procedure. She also is hesitant to undertake her own hygienic care and grooming. The nurse who is culturally aware recognizes that which of the following may be true for this patient? a. She is dependent on health care providers. b. She relies on family members to assist with her care. c. She lacks motivation to participate in self-care. d. She is in denial of traditional medical treatment.

ANS: B Feedback A A dependence on health care providers would be unlikely in this case, as non-Western cultures are more inclined to depend on family members. B Non-Western cultures may rely on family members to provide care. C Self-care is a caring pattern of Western cultures. The patient's behaviour is more likely a result of her cultural background than of a lack of motivation. D The patient's behaviour is not indicative of denial of traditional treatment, but rather it is indicative of her cultural expectations.

Which of the following is a product of critical thinking that focuses on problem resolution? a. Assessment b. Decision making c. Clinical inference d. Diagnostic reasoning

ANS: B Feedback A Assessment is not a product of critical thinking that focuses on problem resolution. B Decision making is a product of critical thinking that focuses on problem resolution. C Clinical inference is a part of diagnostic reasoning. D Diagnostic reasoning is a process of determining a patient's health status after making observations, and assigning meaning to those observations.

What is the first step in the implementation process? a. Providing care b. Reassessing the client c. Reviewing and revising the existing nursing care plan d. Organizing resources and care delivery before delivering an intervention

ANS: B Feedback A Before implementing care, the client must be reassessed and the existing nursing care plan must be reviewed and revised. B Reassessment provides a way to determine whether the proposed nursing action is still appropriate for the client's level of wellness. Assessment is a continuous process that occurs each time the nurse interacts with the client. C Before reviewing and revising the existing nursing care plan, the client must be reassessed. D Before organizing resources and care delivery, the client must be reassessed and the existing nursing care plan must be reviewed and revised.

Which of the following provides the best example of a nursing-sensitive client outcome? a. Collaboration b. Decrease in pain c. Medication compliance d. Attending psychiatric outpatient appointments

ANS: B Feedback A Collaboration is not an example of a nursing-sensitive client outcome; it is an activity in which the nurse may engage. B A nursing-sensitive client outcome is a measurable client or family state, behaviour, or perception largely influenced by and sensitive to nursing interventions. A client outcome of decrease in pain is an example of a nursing-sensitive client outcome. C Medication compliance is not the best example of a nursing-sensitive client outcome, as the nurse may not have engaged in interventions to enable the client to become compliant. D Attending psychiatric outpatient appointments is not an example of a nursing-sensitive client outcome.

The nurse recognizes the terminology that applies to culture and ethnicity. Which one of the following selections defines ethnicity? a. An appreciation for differences within another group and the promotion of respect for those differences b. A common identity with members sharing social and cultural heritage c. Many cultures coexisting and maintaining cultural differences d. The belief that one's own race or culture is more valuable than those of others

ANS: B Feedback A Cultural pluralism is a perspective that appreciates another group for being different and "promotes respect for the right of others to have different beliefs, values, behaviours, and ways of life" (Racher & Annis, 2012, p. 159). B Ethnicity refers to a shared identity related to social and cultural heritage, including values, language, geographic space, and racial characteristics. The most important characteristic of an ethnic group is that its members feel a sense of common identity. Race refers to the common biological attributes shared by a group. C Multiculturalism is regarded as a fundamental characteristic of Canadian society. Many cultures coexist in our society and maintain their cultural differences. D Ethnocentrism is a tendency to hold one's own race or culture as more valuable than those of others.

Which of the following is often missing when writing nursing interventions and is acknowledged as a frequent error? a. Etiology b. Frequency c. Action verbs d. Purpose of the intervention

ANS: B Feedback A Etiology is part of a nursing diagnosis. B One of the four cited frequent errors in writing nursing interventions is failure to indicate frequency; the other three are failure to precisely or completely indicate nursing actions, failure to indicate quantity, and failure to indicate method. C Action verbs are not identified as being a frequent error when writing nursing interventions. D The purpose of the intervention is not part of writing a nursing intervention.

Time takes on different meanings from one culture to another. Understanding this, what should the nurse do when planning nursing interventions? a. Avoid using set times for procedures. b. Mutually negotiate time schedules with clients. c. Encourage patients to set their own times for care, regardless of the schedule. d. Maintain the set times for treatments and inform patients of the schedule.

ANS: B Feedback A For organizational purposes, the nurse should seek the patient's input, and together the nurse and the patient may set a time to perform procedures. B Differences exist in the dimensions of time that cultures emphasize and the manner by which time is expressed. Improving patients' access to health services may be achieved through time schedules that are mutually negotiated, allowing for cultural patterns to be respected. C Although the patient's input should be sought, it is not realistic to have patients set their own times for nursing care activities regardless of the schedule. Some procedures may be required more frequently than the patient would set, or the nurse may be unable to meet the needs of several patients on the unit at the same time. D Maintaining set times for treatments and informing the patient of the schedule does not take into consideration the patient's time orientation.

When an etiological factor cannot change, at which of the following should interventions be directed? a. Eliminating risk factors b. Treating signs and symptoms c. Creating a safe environment for the client d. Understanding the scientific rationale for the interventions

ANS: B Feedback A For potential or high-risk diagnoses, interventions should be directed at altering or eliminating risk factors for the diagnosis. B When an etiological factor cannot change, interventions are to be directed at treating the signs and symptoms. C Creating a safe environment is an example of an activity for physical comfort promotion intervention-environmental management. D Understanding the scientific rationale for the intervention is the capability of the nurse.

Which of the following domains of health seeks prevention programs for populations as its main focus? a. Global health b. Public health c. International health d. Transcultural health

ANS: B Feedback A Global health embraces both prevention in populations and clinical care of individuals. B The main focus of public health is prevention programs for populations. C International health embraces both prevention in populations and clinical care of individuals. D Transcultural health is not a domain of health.

Regardless of which cultural assessment model the nurse uses, how would the nurse begin a cultural assessment? a. Identify the dominant culture. b. Become aware of the population demographic changes within the practice setting. c. Assess care expressions as well as patterns and practices of health. d. Ensure biocultural ecology and health risks of the dominant culture.

ANS: B Feedback A Identifying the dominant culture is not the first step in a cultural health assessment. B Whichever cultural assessment model is used, the nurse begins a cultural assessment by knowing population demographic changes in the practice setting. C Assessing care expressions as well as patterns and practices of health is part of assessing influence and is not the first step in a cultural assessment. D Ensuring biocultural ecology and health risks is not the first step in a cultural assessment.

Which of the following is true in regard to a source record? a. Interprofessional documentation is involved. b. Content is organized by discipline. c. It documents deviations from the norm. d. It documents the source of the patient problem.

ANS: B Feedback A Interprofessional documentation occurs with a case management model of care. B In a source record, the patient's chart is organized so that each discipline has a separate section. C Documenting deviations from the norm is a characteristic of charting by exception. D Documenting the source of the patient problem is part of PIE charting.

The nurse recognizes the terminology that applies to culture and ethnicity and its correct application. Which of the following would be true for a patient who goes through the process of assimilation? a. The patient will coexist with people of other cultures in society and maintain his or her own cultural differences. b. The patient will gradually adopt the attitudes and customs of the mainstream culture. c. The patient will socialize within his or her primary cultural group. d. The patient will treat people unfairly based on group membership.

ANS: B Feedback A Multiculturalism, regarded as a fundamental characteristic of Canadian society, involves many cultures coexisting in society and maintaining their cultural differences. B Assimilation occurs when a minority group gradually adopts the attitudes and customs of the mainstream culture. C Socialization into one's primary culture is known as enculturation. D Discrimination is the act of treating people unfairly based on group membership.

After visiting with a client, the nurse documents the assessment data. Both objective and subjective information have been obtained during the assessment. Which of the following is classified as objective data? a. Pain in the left leg b. Elevated BP c. Fear of surgery d. Discomfort with breathing

ANS: B Feedback A Subjective data are clients' perceptions about their health problems, such as pain. B Objective data are observations or measurements made by the data collector, such as a BP reading. C Fear of surgery would be subjective data because it is the client's perception and not something the data collector can measure. D Subjective data are clients' perceptions about their health problems, such as discomfort with breathing. A respiratory rate measurement would be an example of objective data.

What is the primary source of data for evaluation? a. The chart b. The client c. The end-of-shift report d. Interprofessional team meetings

ANS: B Feedback A The chart is not the primary source of data for evaluation. B The primary source of data for evaluation purposes is the client. C The end-of-shift report is not the primary source of data for evaluation. D The nurse may use input from other caregivers in an interprofessional team meeting, but this is not the primary source of data for evaluation.

The client is seen in the clinic for her first prenatal visit. The nurse formulates a nursing diagnosis of Knowledge deficit related to complications of pregnancy. One outcome criterion is that the client can state five symptoms that indicate a possible problem that should be reported. The client is able to tell the nurse three symptoms. What would the nurse's evaluation statement be? a. "Goal met; client able to state three symptoms." b. "Goal partially met; client able to state three symptoms." c. "Goal not met; client unable to list five symptoms." d. "Goal not met; client able to list three symptoms."

ANS: B Feedback A The client's ability to state three symptoms does not meet or exceed the outcome criterion of the client's being able to state five symptoms. B The client is showing changes but does not yet meet criteria set; therefore, the goal is partially met. C If the client were showing no progress, then the goal would not be met. However, this client's response does indicate some change. D The client's ability to list three symptoms demonstrates some change. If the client were showing no progress, then the goal would be not met.

When documenting a comprehensive nursing health history, under which variable would the nurse document the client's number of children? a. Spiritual b. Developmental c. Psychological d. Sociocultural

ANS: B Feedback A The number of children a client has is not a psychological variable. B The number of children a client has is an example of a developmental variable, which is one part of a comprehensive nursing health history. C The number of children a client has is not a spiritual variable. D The number of children a client has is not a sociocultural variable.

Which of the following is evaluated as a legally appropriate notation? a. "Dr. Green made an error in the amount of medication to administer." b. "Patient verbalized sharp, stabbing pain along the left side of chest." c. "Nurse Williams spoke with the patient about the surgery." d. "Patient upset about the physiotherapy."

ANS: B Feedback A The nurse should not document "physician made error." Instead, the nurse could chart, "Dr. Green was called to clarify order for medication administration." B Entries should be concise, factual, and accurate. The entry "Patient verbalized sharp, stabbing pain along the left side of chest" is an example of an objective description of a patient's behaviour. C The nurse should chart only for himself or herself. In this case, Nurse Williams should write the charting entry. D Only objective descriptions of the patient's behaviour should be recorded. For example, "Patient states, 'I don't want physiotherapy! I want to go home!'"

Which of the following abilities on the part of the client will the nurse evaluate based on the following outcome criterion determined by the nurse: "Client will independently complete necessary assessments before administration of digoxin"? a. Assessing the respiratory rate b. Palpating the radial pulse c. Reviewing dietary habits d. Inspecting colour of the skin

ANS: B Feedback A The outcome criterion does not state anything about exercise. During evaluation, the nurse is to judge the degree of agreement between the outcome criterion and the client's behaviour. B The nurse should compare the established outcome criterion with the client's behaviour or response. In this case, the client is expected to independently complete the necessary assessments before administration of digoxin. The client should be able to palpate the radial pulse as an assessment before administration of digoxin. C The outcome criterion does not state anything about diet. Evaluating whether the client reviews his or her own dietary habits would not be comparable to a necessary assessment before medication administration. D The outcome criterion does not state anything about the client's skin. The nurse, who knows that digoxin is a cardiotonic, understands that the client should be assessing his or her own heart rate.

What is the first step the nurse should take upon beginning the process of data collection? a. Physical examination b. Client interview c. Review of medical records d. Discussion with other health team members

ANS: B Feedback A The physical examination follows the client interview so that data can be verified. B The first step in establishing the database is to collect subjective information by interviewing the client. C A review of medical records is not the first step the nurse should take in the process of data collection. The medical record is a valuable tool for checking the consistency and congruency of personal observations made during the client interview. D Discussion with other health team members may provide additional information and be used to relay information, but it is not the first step in the process of data collection.

The nurse is discussing with an Aboriginal patient long-term goals for a diet and exercise regimen to manage his diabetes. The nurse notices that he does not appear concerned about discussing his future needs. Which of the following is a possible reason for this behaviour? a. His cultural time orientation is to the past. b. He believes in living day by day. c. He believes that there is no point in worrying about what has not yet happened. d. His belief is that time will heal his condition.

ANS: B Feedback A The statement "His cultural time orientation is to the past" is not a determining factor for future needs. B Aboriginal life choices and the responsibility to choose, and a belief in living day by day may help to explain why the patient does not appear interested in discussing the future of his diabetes management. C The statement "He believes that there is no point in worrying about what has not yet happened" does not reflect Aboriginal values or beliefs. D The statement "His belief is that time will heal his condition" does not reflect Aboriginal values or beliefs.

When documenting care that has been implemented by the nurse, what is the term used to describe an older adult who is living in a long-term care or residential facility? a. Client b. Patient c. Resident d. Individual

ANS: C Feedback A "Client" is not the correct term to describe an older adult living in a long-term care or residential facility. B "Patient" is not the correct term to describe an older adult living in a long-term care or residential facility. C Older adults living in a long-term care or residential facility often live there the rest of their lives, and therefore are referred to as "residents" rather than "clients" or "patients." D "Individual" is not the correct term to describe an older adult living in a long-term care or residential facility.

A client states, "I am so depressed." Which of the following interview questions will best elicit more information from the client? a. "How long have you felt this way?" b. "Have you ever felt this sad before now?" c. "What do you think is the cause of your feeling depressed?" d. "When did you start having feelings of depression?"

ANS: C Feedback A "How long have you felt this way?" is a closed-ended question requiring only a "yes" or "no" response, and so provides minimal information regarding the client's condition. B "Have you ever felt this sad before?" is a closed-ended question requiring only a "yes" or "no" response, and so provides minimal information regarding the client's condition. C Open-ended questions elicit more in-depth information from clients. "What do you think is the cause of your feeling depressed?" is an open-ended question that encourages the client to express his or her own insight and personal stories regarding his or her condition. D "When did you start having feelings of depression" is a closed-ended question requiring only a "yes" or "no" response and so provides minimal information regarding the client's condition.

Which one of the following does the nurse recognize as the primary purpose of a nursing diagnosis? a. Support the medical plan of care. b. Provide a standardized approach for all clients. c. Recognize the client's response to an illness or situation. d. Offer the nurse's subjective view of the client's behaviours.

ANS: C Feedback A A nursing diagnosis is based on the client, not on the medical plan of care. B Although nursing diagnoses may facilitate communication, they do not provide a standardized approach for all clients. Nursing diagnoses are individualized to meet the client's specific needs. C The primary purpose of a nursing diagnosis is to recognize the client's response to an illness or situation. The nurse can then use the nursing diagnosis to select appropriate nursing interventions to achieve positive client outcomes. D The primary purpose of nursing diagnoses is not to offer the nurse's subjective view of the client's behaviours. Nursing diagnoses are based on subjective and objective client data and should not include the nurse's personal beliefs and values.

The nurse may work with patients from many different cultural backgrounds. Nurses, unfortunately and inadvertently, may impose their own cultural beliefs on patients. Which of the following is an example of a nurse imposing personal perspectives on a patient? a. Adapting the patient's room to accommodate extra family members who are visiting b. Seeking information on gender-congruent care for an Egyptian patient c. Directing an older Chinese patient to do rehabilitation exercises after she has refused to do them until her daughter arrives d. Encouraging family members to assist with the patient's care when it is appropriate for them to do so

ANS: C Feedback A Adaptation of the patient's room to accommodate extra family members is not an example of cultural imposition on a patient but rather is meeting the patient's need by providing culturally congruent care. B Seeking information on gender-congruent care for an Egyptian patient is an example of the desire to provide culturally congruent care. C In collectivistic cultures that value group reliance and interdependence, such as traditional South Asians, caring behaviours are manifested by actively providing physical and psychological support for kin members. The nurse may perceive the patient's refusal of exercise as lack of motivation for self-care, and in this case the nurse is imposing her own belief system. D Encouraging family members to assist with the patient's care is not an example of cultural imposition on a patient. Western culture tends to follow a pattern of caring that focuses on self-care and self-determination, whereas non-Western cultures typically have care provided by others.

Which of the following statements is true in regard to ethnocentrism? a. Ethnocentrism involves adopting the attitudes and customs of another culture. b. Ethnocentrism involves many cultures coexisting and maintaining differences. c. Ethnocentrism involves viewing one's own way of life as more valuable than other ways. d. Ethnocentrism involves an appreciation of cultural differences and rejects assumptions of superiority.

ANS: C Feedback A Assimilation involves adopting the attitudes and customs of another culture. B Multiculturalism involves many cultures coexisting and maintaining differences. C Ethnocentrism is a tendency to view one's own way of life as more valuable than others'. D Cultural relativism involves an appreciation of cultural differences and rejecting assumptions of superiority.

A Chinese family that has been in Canada for five years has learned to speak English and has adopted certain Western characteristics, but has continued to adhere to their values, beliefs, and traditions. What is this process called? a. Assimilation b. Enculturation c. Acculturation d. Multiculturalism

ANS: C Feedback A Assimilation is a process whereby a minority group gradually acquires the attitudes and customs of the mainstream culture. B Socialization into one's primary culture as a child is known as enculturation. C Acculturation is the process of adapting to or adopting the characteristics of a new culture. D Multiculturalism is prevalent in Canadian society, where many cultures coexist while maintaining their cultural differences.

During which aspect of the nursing process will the nurse most likely consult with other health professionals? a. Assessment b. Diagnosis c. Implementation d. Evaluation

ANS: C Feedback A Consultation can occur in assessment, but it occurs most frequently in planning and implementation. B Nursing diagnoses are an independent action of the nurse. C Although consultation can occur at any step in the nursing process, it occurs most often during the planning and implementation phases, when problems necessitating additional knowledge, skills, or resources arise. D Consultation can occur in evaluation, but it occurs most frequently in planning and implementation.

The nurse is working with postoperative clients on a surgical unit. One aspect of care is manipulation of the client's environment. What does this involve on the part of the nurse? a. Delegating ambulation of clients to the unregulated care provider b. Providing pain medication to the client before a dressing change c. Maintaining client privacy during procedures d. Repositioning the client every two hours

ANS: C Feedback A Delegating ambulation of clients to the unregulated care provider is an example of organizing personnel (resources) for care delivery. B Providing pain medication before a dressing change is an example of organizing care delivery specific to the client. Before beginning to perform interventions, the nurse should make the client as physically and psychologically comfortable as possible. C Maintaining client privacy during procedures that may require some body exposure is an example of manipulating the client's environment. A care environment must be safe and conducive to implementation of therapies. D Repositioning the client every two hours is an example of organizing care delivery to promote client comfort and prepare the client for nursing intervention.

Which of the following levels of critical thinking is an example of critical thinking at the complex level? a. Following a procedure for catheterization step by step b. Giving medication at the time ordered c. Discussing alternative pain management techniques d. Reviewing the patient's medical records thoroughly

ANS: C Feedback A Following a procedure step by step is an example of the basic level of critical thinking. B Giving medication at the time ordered is an example of the basic level of critical thinking. C Discussing alternative pain management techniques is an example of critical thinking at the complex level. The nurse analyzes and examines alternatives more independently, taking into consideration more creative and innovative options in exploring a broad range of perspectives and alternatives. D Reviewing the patient's medical records thoroughly is an example of gathering data and may be used in the evaluation of a patient's care.

Gender-appropriate care is an important factor in nursing practice. The nurse recognizes that patients of different cultures may react differently to health care providers of the opposite sex. Modesty is an especially important issue for women from which of the following backgrounds? a. Black Canadian b. Aboriginal c. Egyptian Canadian d. Filipino Canadian

ANS: C Feedback A Modesty is not an especially important issue for Black Canadian women. B Modesty is not an especially important issue for Aboriginal women. C Modesty is a strong value among Egyptian Canadian women. D Modesty is not an especially important issue for Filipino Canadian women.

Which of the following is an example of an indicator for the nursing diagnosis of pain? a. Pain level b. Pain control c. Muscle tension d. Description of disease process

ANS: C Feedback A Pain level is a suggested outcome for the nursing diagnosis of pain. B Pain control is a suggested outcome for the nursing diagnosis of pain. C Muscle tension is an example of an indicator for the nursing diagnosis of pain. D Description of disease process is an example of an indicator, but it is not an example related to the diagnosis of pain; rather, it is an example of an indicator with a diagnosis of deficient knowledge.

When modifying a care plan to meet a client whose status has changed significantly over the past few days, what should the nurse do? a. Redevelop the entire client care plan. b. Focus on changing the nursing diagnoses and goals. c. Perform a complete reassessment of all client factors. d. Add more nursing interventions from a standardized plan of care.

ANS: C Feedback A Reassessment may not require redoing the entire care plan. B The nurse should not focus only on the nursing diagnoses and goals that have changed; nursing interventions may also need revising to meet new goals. Adding more nursing interventions may or may not be necessary. The nurse adjusts interventions on the basis of the client's response and the nurse's previous experience with similar clients. C A complete reassessment of all client factors relating to the nursing diagnosis and etiology is necessary when modifying a plan. After reassessment, the nurse will determine what components of the care plan are accurate for the situation. D Standards of care are used to determine whether the right interventions have been chosen or whether additional ones are required.

The nurse has determined the following outcome for a client with a skin impairment: "Erythema will be reduced in three days." On what will the evaluation specifically focus? a. Selection of appropriate wound care b. Notation of the odour and colour of drainage c. Inspection of the colour and condition of the area d. Measurement of the diameter of the ulceration daily

ANS: C Feedback A Selection of appropriate wound care is an intervention, not an evaluation of a client's behaviour or response. The outcome criterion does not state anything about drainage. B Noting the colour and amount of drainage may be a part of reassessment of the client but is not what the nurse is evaluating according to this outcome criterion. C Erythema is reddening of the skin; therefore, the evaluation should specifically focus on inspection of the colour of the skin, as stated in the outcome criterion. D The outcome criterion states that the erythema, not the size of the ulceration, will be reduced. During the evaluation step of the nursing process, the client's behaviour or response should be compared to the outcome criterion and judged for the degree of agreement between the two.

Which of the following types of documentation is represented by the statement, "Patient is wheezing and experiencing some dyspnea on exertion"? a. The "S" in SOAP documentation b. Focus documentation c. The "P" of PIE documentation d. The "R" in DAR documentation

ANS: C Feedback A The "S" in SOAP documentation represents subjective data (verbalizations of the patient). B Focus charting does not concentrate on problems only. C The statement is an example of the "P" of PIE documentation because it describes the patient's problem. D The "R" in DAR documentation is the response of the patient. This situation describes the patient's problem, not the patient's response.

The nurse tells an advanced nurse practitioner that the patient is "slipping a little" in reference to hemodynamic pressures. Which communication technique is the nurse using? a. Brevity b. Relevance c. Pacing and control d. Connotative meaning

ANS: D Feedback A Brevity means that communication is simple, brief, and direct. "Slipping a little" is not an example of using brevity. B Relevance means that the message is relevant or important to the situation at hand. "Slipping a little" is not an example of using relevance. C Pacing and control means speaking slowly enough to enunciate clearly and not changing subjects rapidly. Saying that a patient is "slipping a little" is not an example of using pacing and control. D The connotative meaning is the shade or interpretation of a word's meaning influenced by the thoughts, feelings, or ideas people have about the word. "Slipping a little" in reference to hemodynamic pressures is an example of using connotative meaning.

The client is able to ambulate without signs or symptoms of shortness of breath. Which of the following statements by the nurse is the best example of an objective evaluation of the client's goal attainment? a. "Client has no pain after ambulating." b. "Client has no manifestations of nausea while up in hall." c. "Client has no evidence of respiratory distress when ambulating." d. "Client walked well and did not have any problem when up."

ANS: C Feedback A The statement, "Client has no pain after ambulating," does not use the same evaluative measure gathered during assessment. The assessment measure concerned respiratory changes during ambulation, not pain. If the client's pain level were going to be used as an evaluative measure, it would be optimal to have the client report the pain by using a pain scale to make it more measurable for comparison. B The statement, "Client has no manifestations of nausea while up in hall," is not the best example of an objective evaluation of the client's goal attainment. It does not use the same evaluative measure gathered during assessment. The assessment measure concerned respiratory changes during ambulation, not nausea. Also, the client's feeling of nausea is subjective data. C "Client has no evidence of respiratory distress when ambulating" is the best example of an objective evaluation of the client's goal attainment. It uses the same evaluative measures gathered during assessment and clearly describes objective data. D "Client walked well and did not have any problem when up" is not the best example of an objective evaluation. It includes the nurse's interpretation rather than documentation of objective data.

What is the link between the nursing diagnosis and the medical diagnosis? a. The time frame of awareness b. Potential mobility problems c. Client's chief medical diagnosis and priority assessments d. Health promotion activities and education to motivate for wellness

ANS: C Feedback A The time frame of awareness is not the link between nursing and medical diagnosis. B Potential mobility problems could be a specific nursing diagnosis, but this diagnosis does not apply in all cases. C The link between nursing and medical diagnoses is the client's chief medical diagnosis and priority, individualized assessments. D Health promotion activities and education to motivate people to be healthy is not the link between nursing and medical diagnoses.

Where does the nurse record a description of the teaching provided to the patient on performance of self-medication administration? a. Kardex form b. Incident report c. Nursing history form d. Discharge summary form

ANS: D Feedback A A Kardex form is a written form that contains basic patient information. A Kardex form contains an activity and treatment section, and a nursing care plan section that organizes information for quick reference as nurses give change-of-shift reports. It does not include a description of teaching that was provided to the patient. B An incident report concerns any event that is not consistent with the routine operation of a health care unit or routine care of a patient (e.g., a patient falls). C A nursing history form guides the nurse through a complete assessment to identify relevant nursing diagnoses or problems. It provides baseline data about the patient. D The nurse's description of the teaching provided to the patient on performance of self-administration of medication is recorded in the discharge summary form.

Which of the following is measurable along a continuum in response to a nursing intervention? a. Client goal b. Nursing diagnosis c. Time-limited nursing intervention d. Nursing-sensitive client outcome

ANS: D Feedback A A client goal is not measurable along a continuum in response to a nursing intervention. B A nursing diagnosis is not measurable along a continuum in response to a nursing intervention. C A goal, not a nursing intervention, is time-limited. D A nursing-sensitive client outcome is defined as an individual, family, or community, behaviour, or perception that is measurable along a continuum in response to a nursing intervention.

The nurse has provided the patient with information regarding the treatment plan for the diagnosis. The patient tells the nurse that he understands most of the information but still has questions concerning the medication. This response is an example of what? a. A referent b. A receiver c. A channel d. Feedback

ANS: D Feedback A A referent (e.g., a communication trigger such as a time schedule) motivates one person to communicate with another. The patient's response is not an example of a referent. B The receiver is the person who receives and decodes the message. The question is asking about the response, not about the receiver. C Channels are means of conveying and receiving messages through visual, auditory, and tactile senses. The patient's response is not an example of a channel. D The patient's response is an example of feedback. Feedback is the message returned by the receiver.

The charge nurse is evaluating patient documentation of a new staff nurse. Based on which of the following does the charge nurse note, on review of the new nurse's charting, that appropriate documentation is evident? a. A pencil was used to make the entries. b. Correction fluid was used to correct written errors. c. An error made by the attending physician was documented. d. All of the entries he or she made in the record were dated and signed.

ANS: D Feedback A All entries should be recorded legibly and in black ink, because pencil can be erased. B The nurse should never erase entries or use correction fluid, and never use a pencil. The use of correction fluid could render the charting illegible, and it might appear as if the nurse were attempting to hide something or deface the record. C If the physician made an error, the nurse should not document it in the patient's chart; the error should be documented in an incident report. D Each entry should begin with the time of entry and end with the signature and title of the nurse who recorded the entry.

To avoid legal risks and possible lack of confidentiality associated with computerized documentation, which of the following statements is true of many current software programs? a. All nursing staff use the same access code. b. Only centralized medical records use the patient data. c. Thumbprint identification restrictions are in place. d. Staff password changes are periodically required.

ANS: D Feedback A All nurses do not use the same access code. Each nurse should have his or her own password. B "Only centralized medical records use the patient data" is not a true statement. Authorized health care providers from any department can access and use the data. C Many software programs do not have thumbprint identification restrictions. D A good system of computerized documentation requires frequent and random periodic changes in personal passwords to prevent unauthorized persons from tampering with records.

Which of the following best reflects the philosophy of critical thinking as taught by a nurse teacher to a nursing student? a. "Don't draw subjective inferences about your patient; be more objective." b. "Please think harder; I am looking for a single solution." c. "Trust your feelings; don't be concerned about trying to find a rationale to support your decision." d. "Think about what is important in the situation, and make informed decisions about the patient's concerns."

ANS: D Feedback A Drawing inferences is a specific critical thinking competency used in diagnostic reasoning. The nurse teacher who tells the nursing student not to draw inferences is not allowing the student to practice competencies necessary for specific critical thinking in clinical situations. B The critical thinker will look beyond a single solution to a problem. C Intuition develops as one's clinical experience increases. The nursing student should examine rationales to make good decisions. D The nurse teacher is asking the nursing student to recognize the importance of an issue and how to make informed decisions with regard to patient concerns. Critical thinking involves recognizing an issue, analyzing information about the issue, evaluating the information, and drawing conclusions in order to proceed with care in consultation with the patient.

Which of the following statements is true in regard to health inequity? a. Health differences are unavoidable. b. Poverty is not a root cause of health inequity. c. Health inequity is the absence of systematic disparities in health. d. Health inequity refers to unnecessary and unfair differences in health.

ANS: D Feedback A Health differences are seen as avoidable. B Poverty is often a root cause of health inequity. C The absence of systematic disparities in health is characteristic of health equity. D Health inequities refer to differences in health that are not only unnecessary and avoidable but, in addition, are considered unfair and unjust.

Which of the following is true about a flow sheet? a. Information is outdated. b. The quantity of narrative notes is increased. c. There is an increased chance of errors from transfer of information. d. Team members can quickly identify trends over time of care.

ANS: D Feedback A Information is current with a flow sheet, not outdated. B Time spent on narrative notes is decreased with a flow chart, not increased. C There is a decreased chance of transfer of information errors with flow charts, not an increased chance. D One of the benefits of using a flow sheet is that team members can quickly see trends over time.

Which of the following represents the three phases of a client interview? a. Introduction, assessment, conclusion b. Orientation, documentation, database c. Introduction, controlling, selection d. Orientation, working, termination

ANS: D Feedback A Introduction, assessment, and conclusion are not the three phases of a client interview. B Orientation, documentation, and database are not the three phases of a client interview. C Introduction, controlling, and selection are not the three phases of a client interview. D The three phases of a client interview are orientation, working, and termination.

The nurse is completing an assessment of a First Nations client. Recognizing the commonly seen health problems in Aboriginal peoples, the nurse observes for particular signs and symptoms of which one of the following conditions? a. Hypertension b. Parasitic infections c. Tay-Sachs disease d. Diabetes mellitus

ANS: D Feedback A Malignant hypertension is a genetic link seen in Black Canadians. B Parasitic infections are often seen in immigrants from an area near the Nile River. C Tay-Sachs disease is common among Ashkenazi Jews. D Diabetes mellitus is considered to be an epidemic in progress for Canadian Aboriginal peoples. The presence of diabetes among Aboriginals is three to five times the national average, based on location, than in non-Aboriginal communities.

Why does the nurse use nursing diagnoses after completing the client assessment? a. Nursing diagnoses make it quicker and easier to resolve all client problems. b. Nursing diagnoses assist the nurse to distinguish medical from nursing problems. c. Nursing diagnoses are required by law across Canada. d. Nursing diagnoses identify client problems that have a nursing focus.

ANS: D Feedback A Nursing diagnoses may facilitate communication among health providers, but they do not necessarily render all client problems more quickly and easily resolved. B Medical problems are identified with medical diagnostic statements to treat a disease condition. Nursing diagnoses describe the client's actual or potential response to a health problem that the nurse is licensed and competent to treat. Nursing diagnoses distinguish the nurse's role from that of the physician. C Although the nursing diagnosis is part of basic nursing preparation in Canada, it has not yet been incorporated into provincial or territorial nursing practice standards or legislation. The exceptions are Ontario and Saskatchewan, where practice standards require the formulation and documentation of nursing diagnoses D After completing the client assessment, the nurse develops nursing diagnoses based on the data obtained. Nursing diagnoses distinguish the nurse's role from that of the physician and help the nurse to focus on the role of nursing in client care.

The patient draws back when the nurse reaches over the side rails to take his blood pressure. What should the nurse do first to promote effective communication? a. Tell the patient that the blood pressure can be taken at a later time. b. Rotate the nurses who are assigned to take the patient's blood pressure. c. Continue to perform the procedure quickly and quietly. d. Apologize for startling the patient and explain the need for contact.

ANS: D Feedback A Telling the patient that the blood pressure can be taken at a later time does not promote effective communication. B Rotating the nurses who are assigned to take the patient's blood pressure impedes the nurse's ability to form a therapeutic, helping relationship. C Continuing to perform the procedure quickly and quietly may send a negative nonverbal message to the patient. It also does not promote effective communication. D Nurses often have to enter a patient's personal space to provide care. The nurse should convey confidence, gentleness, and respect for privacy. Apologizing for startling the patient and explaining the need for contact demonstrates respect and provides information so the patient can understand the need for personal contact.

Guidelines should be followed when documenting patient care. Which one of the following does the nurse recognize as the most appropriate notation? a. "1230 hours: Patient's vital signs taken" b. "0700 hours: Patient drank adequate amount of fluids" c. "0900 hours: Morphine given for lower abdominal pain" d. "0830 hours: Increased IV fluid rate to 100 mL per hour"

ANS: D Feedback A The entry "1230 hours: Patient's vital signs taken" does not indicate what the patient's vital signs were. B The entry "0700 hours: Patient drank adequate amount of fluids" does not provide the specific amount that the patient drank. Stating "adequate" is subjective, not objective. C The notation "0900 hours: Morphine given for lower abdominal pain" does not have the patient describe his or her pain, or rate it according to a pain scale for comparison later. It also does not indicate whether the patient's pain was in the lower left or lower right quadrant, or both. D Information within a recorded entry must be complete, containing appropriate and essential information. The notation "0830 hours: Increased IV fluid rate to 100 mL per hour" provides the time and action taken by the nurse, including the reason for doing so.

The nurse begins to auscultate the client's lungs. While listening, the nurse notices fresh bloody drainage oozing from the abdominal dressing. The nurse stops auscultating and applies direct pressure to the wound site. Of what is this nursing action an example? a. Performing a nursing assessment b. Reorganizing the nursing diagnoses c. Setting realistic goals and implementing nursing interventions d. Critically analyzing the data and effectively implementing the safest nursing action

ANS: D Feedback A The nurse is doing more than performing a nursing assessment; the nurse is taking action based on new assessment data. B The nurse is not reorganizing nursing diagnoses; the nurse is implementing the priority nursing action. C The scenario is not an example of setting realistic goals and implementing nursing interventions. Applying direct pressure to a wound site to stop bleeding demonstrates critical analysis of the data and implementation of the safest nursing action. D The nurse who stops auscultating lung sounds to take measures to stop noticeable bleeding is analyzing data presented, as demonstrated by the nurse's setting priorities, and is effectively implementing the safest nursing action.

The nurse is preparing the information that will be provided to the staff on the next shift. Which of the following should the nurse include in the change-of-shift report to nursing colleagues? a. A description of the steps of procedures done b. A review of routine care for the patient c. All routine care procedures required by the patient d. Essential background information about the patient

ANS: D Feedback A The nurse should relay to staff significant changes in the way therapies are given but should not describe basic steps of a procedure in a change-of-shift report. B The nurse should not review routine care procedures or tasks in a change-of-shift report. C The nurse should not review all routine care procedures or tasks in a change-of-shift report. D A change-of-shift report should include essential background information about the patient (i.e., name, sex, age, physician's diagnosis, and medical history).

A faculty member is reviewing a process recording with the student nurse. The student has been working with a patient who has had an amputation of the lower left leg and is emotionally fragile. Which of the following responses made by the student to the patient receives positive feedback from the faculty member? a. "Why are you so upset today?" b. "I'm sure that everything will be all right." c. "You shouldn't cry. The wound will heal soon." d. "It must be very difficult to have this happen to you."

ANS: D Feedback A The question, "Why are you so upset today?", is an example of a nontherapeutic communication technique of asking for explanations. B The response, "I'm sure that everything will be all right", is an example of a nontherapeutic communication technique of giving false reassurance. C The response, "You shouldn't cry. The wound will heal soon", is an example of a nontherapeutic communication technique of giving disapproval. D The statement, "It must be very difficult to have this happen to you," is an example of using the therapeutic communication technique of sharing empathy. It is the ability to understand another person's reality, to accurately perceive unspoken feelings, and to communicate this understanding to the other person.

Which one of the following is an example of a nurse's statement that reflects using the scientific method in the nursing process? a. "My instincts tell me that the patient is getting depressed." b. "The patient doesn't look the same today. I think something is wrong." c. "The patient's husband told me that the patient is feeling uncomfortable." d. "The patient seems to be having more pain today than yesterday, and her blood pressure (BP) is elevated."

ANS: D Feedback A The statement "My instincts tell me that the patient is getting depressed" reflects intuition. B The statement "The patient doesn't look the same today. I think something is wrong" reflects intuition. C The statement "The patient's husband told me that the patient is feeling uncomfortable" reflects information gathering, which may be used in diagnostic reasoning. D The statement "The patient seems to be having more pain today than yesterday, and her BP is elevated" reflects using the scientific method in the nursing process. The nurse identified a problem of pain, hypothesized that it was greater than it was the day before, and collected data to evaluate its reality.

The nurse may use a concept map when implementing a plan of care. What is the purpose and distinction of a concept map? a. Quality assurance in the health care facility b. Multidisciplinary communication c. Provision of a standardized format for client problems d. Identification of the relation of client problems and interventions

ANS: D Feedback A The use of a concept map promotes critical thinking and helps the nurse to organize complex client data, process complex relationships, and achieve a holistic view of the client's situation. The purpose is not quality assurance in the health care facility. B Multidisciplinary communication is enhanced with the use of critical pathways, not concept maps. C Standardized or computerized care plans, not concept maps, provide a standardized format for client problems. A concept map is highly individualized. D A concept map is a diagram of client problems and interventions that shows their relations to one another.

The nurse wants to develop an awareness of the practices of different cultures within the community. One aspect of culture is invisible, or less observable to others. Which of the following is an example of this "invisible" component of culture? a. Wearing cotton garments b. Wearing an amulet or charm c. Using prayer beads or candles d. Spiritual connection

ANS: D Feedback A The wearing of cotton garments is a visible (easily seen) component of culture. B An example of a visible (easily seen) component of culture is the wearing of an amulet or charm. C An example of a visible (easily seen) component of culture is the use of prayer beads or candles. D An example of an invisible (less observable) aspect of Aboriginal culture is people's spiritual connection to the natural world. The importance of the harmony of this connection is understood, as is the wholeness that results when the spiritual, physical, mental, emotional, and relational parts of the self are integrated.